Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 16, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 16, 2021 
by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. You do 
not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are 
ambulating more than 100 feet and tending to activities of daily living (ADLs) with minimal supervision. Daily 
skilled services are not required to establish a maintenance program or to prevent deterioration of your 
condition. Your care needs, as a practical matter, can be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xgeva. 
 
You asked the Plan to pre-approve Xgeva. You say that the requested Xgeva is medically necessary. The Plan 
denied your request. The Plan says the enrollee must try and fail zoledronic acid or pamidronate first. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Xgeva. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found based on the medical records 
provided the enrollee has not tried and failed the required drug(s). Based on the medical records provided there 
is no indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects 
for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Xgeva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xgeva.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a gammagard injection provided on April 
19, 2021. We also decided that the Plan does not have to waive the coinsurance for a gammagard injection, a 
methylprednisolone sodium succinate injection, and a diphenhydramine injection provided on May 17, 2021. 
 
You asked the Plan to waive the coinsurance for gammagard injections, a methylprednisolone sodium succinate 
injection, and a diphenhydramine injection. You say that you were informed you would not have any costs 
associated with this treatment. You also say that both you and the provider checked with the Plan, but now you 
have an invoice from the provider. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a total of $1,107.71 coinsurance, which is 20% of the allowed amount for 
gammagard injections, a methylprednisolone sodium succinate injection, and a diphenhydramine injection. 
 
Claim Number: Date of Service: Allowed Amount: Coinsurance: 
820211111348693 4/19/2021       $2766.60             $553.32 
820211391480984 5/17/2021      $2771.91             $554.39 

Total: $5538.51 $1107.71 
   
Gammagard injections, methylprednisolone sodium succinate injections, and diphenhydramine injections fall 
within the Medicare Part B Prescription Drugs benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
coinsurance for a gammagard injection provided on April 19, 2021. We also decided that the Plan does not 
have to waive the coinsurance for a gammagard injection, a methylprednisolone sodium succinate injection, 
and a diphenhydramine injection provided on May 17, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve shoulder surgery (29823, 29820, 29828).

You asked the Plan to pre-approve the shoulder surgery. You say that the procedure is medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the shoulder surgery. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found there are positive exam findings for the left shoulder that correlates with the subjective complaints. These include limited abduction, painful arc of motion/impingement and decreased range of motion in abduction. The imaging studies reasonably corroborate pathology of a partial cuff tear, calcific tendinosis and arthrosis. Reduced activities, Physical therapy, medications, and injections have been tried and failed. In this case the surgical repair is medically appropriate and necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the shoulder surgery have been met. Therefore, we decided that the Plan has to pre-approve shoulder surgery (29823, 29820, 29828). 

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you have a medical condition that 
requires these stockings. The Plan denied your request. The Plan says the criteria is not met. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from September 30, 2021, 
forward. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is not able to go home and needs 
assistance. The Plan denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee no longer qualifies for SNF 
coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have 
documented skilled therapy needs. The enrollee appears to have reached a plateau in function. Daily skilled 
services are not required to establish a maintenance program or to prevent deterioration of the enrollee's 
condition. The enrollee's care needs, as a practical matter, can be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continuation of SNF care from September 30, 2021, forward.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does qualify for SNF coverage. 
The enrollee does not have documented skilled nursing needs. The enrollee does have documented skilled 
therapy needs. The enrollee appears to be functioning below their baseline following several recent 
hospitalizations. The enrollee has made some functional progress during this hospitalization. There is 
insufficient evidence to show that the enrollee has reached a plateau in function. Daily skilled services are 
required to establish a maintenance program and/or to prevent deterioration of the enrollee's condition. The 
enrollee's care needs, as a practical matter, cannot be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on March 1, 2021.

You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation does not support the Place of Service (POS) code billed on this claim.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). 

We looked at the file and Medicare rules. The documentation shows that the sample for this testing was taken in an office setting, therefore the POS code 81 - indicating an independent lab setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on March 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on March 1, 2021.

You asked the Plan to pay for lab tests. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). 

We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing was taken in an office setting, therefore the POS code 81 - indicating an independent lab setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on March 1, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Skilled Nursing Facility services. 
 
You asked the Plan to pre-approve the skilled nursing facility services. You say that the services are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the skilled nursing facility services. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not 
have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance 
program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, 
can be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the skilled nursing facility services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Skilled Nursing Facility services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ForeseeHome age-related macular degeneration 
(AMD) monitoring program. 
 
You asked the Plan to pre-approve the program. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered experimental and investigational for the detection of age-related 
macular degeneration-associated choroidal neovascularization and for all other indications. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the program. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the record indicates that the enrollee has non-exudative age related macular degeneration. The record 
submitted does not contain medical records supportive of the requested service. The provided records are 
insufficient to determine the medical necessity and reasonableness, as defined by Medicare rules, of the 
requested service for the enrollee's specific clinical condition. The elements of the coverage rules are not 
satisfied.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the program have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the ForeseeHome age-related macular degeneration (AMD) monitoring program.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve intravenous immunoglobulin (IVIG). 
 
You asked the Plan to pre-approve IVIG. You say that the requested IVIG is medically necessary. The Plan 
denied your request. The Plan says that the requested IVIG is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IVIG. Our reviewer says that the 
requested IVIG is medically necessary. Our physician reviewer found renal transplant rejection is not an FDA-
approved diagnosis for the use of intravenous immunoglobulin. However, based on Medicare-approved major 
drug compendia there is documentation that supports the use of intravenous immunoglobulin for treatment of 
renal transplant rejection. Based on the medical records provided and the Medicare-approved major drug 
compendia there is documentation that the requested intravenous immunoglobulin is safe and effective and 
otherwise reasonable and necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IVIG have been met. Therefore, we decided that the Plan has to pre-approve 
intravenous immunoglobulin (IVIG).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant-at-surgery services provided on October 26, 
2020, billed with code 13160. 
 
You asked the Plan to pay for the surgical assistant services. You say that these services should be paid. The 
Plan denied your request. The Plan says the denied code is not payable as Medicare does not pay for surgical 
assistant services for this procedure. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 13160. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the
surgical assistant services have not been met. Therefore, we decided that the Plan does not have to pay for the 
assistant-at-surgery services provided on October 26, 2020, billed with code 13160.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the inpatient physician services provided on April 24, 2021, and April 
25, 2021, billed with code 99233. 
 
You asked the Plan to pay for the inpatient physician services. You say that the services should be paid. The 
Plan denied your request. The Plan says that the services cannot be paid as the billed code and place of service 
are invalid. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. No evidence is included in the case file to support that the code/place of service 
(POS) code is incorrect. Without evidence to support that the enrollee was not an inpatient when these services 
were rendered, the denial based on the POS code is not substantiated. Therefore, we decided that the Plan has 
to pay for the inpatient physician services provided on April 24, 2021, and April 25, 2021, billed with code 
99233.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 8, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on February 8, 
2021 by an out-of-network (OON) provider.