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

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 29, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the provider is not Medicare-certified. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are 
furnished by a provider or supplier enrolled in the Medicare program. 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. The file shows that the services were rendered by a provider that is 
not Medicare-certified. Therefore, we decided that the Plan does not have to pay for the laboratory services 
rendered on September 29, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from February 24, 2022, forward.
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 at the time of admission, the member required skilled rehabilitation services to improve function due to weakness and deconditioning. There were no skilled nursing needs. As of February 24, 2022, the member did not require any skilled nursing or rehabilitation services on a daily basis. The member was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living (ADLs). The member did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the member did not require any skilled services on an inpatient basis, at a SNF level of care as of February 24, 2022. The member did not have any parental medications, complex wound care or nutrition given via a feeding tube. The member received skilled care and improved; however, the member's functional improvement had plateaued by February 24, 2022, and the member did not require any further inpatient skilled rehabilitation services. The member's function was at or near their prior level of function and they could be discharged to a lower level of care for further services. As of February 24, 2022, the member required custodial services. The denial for further inpatient skilled care is upheld. 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 February 24, 2022, forward.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis tablets. 
 
You asked the Plan to pre-approve Eliquis tablets. You say that the enrollee's condition is stable on Eliquis. 
The Plan denied your request. The Plan says Eliquis is a self-administered drug and does not fall under Part B 
coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis tablets.  
 
Benefits for Eliquis tablets may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says the enrollee has not 
met the step therapy requirements. 
 
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 Euflexxa. Our reviewer says that 
Euflexxa is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee 
is a 60-year-old male with bilateral knee pain due to bilateral primary osteoarthritis of knee. The enrollee has 
failed conservative therapies including steroid injections and non-steroidal anti-inflammatories with 
radiographs that demonstrate bone on bone arthritis with spur formation and medial joint sclerosis. He has had 
bilateral knee injections with Kenalog and Lidocaine. The provider has requested Euflexxa injections to both 
knees. The enrollee has not trialed viscosupplemental treatments such as Durolane, Gelsyn-3 and 
Synvisc/Synvisc-One. Step therapy, as outlined by the Plan, requires that these be trialed first. The 
documentation does not outline contraindications or reasons these medications were not considered or that the 
Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Without 
the support of the documentation, Euflexxa is not approved as step criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the collection processing and storage of autologous blood 
(86891), special pump services (99190 and 99191) and washed red blood cells (P9022) provided on July 15, 
2021. 
 
You asked the Plan to pay for the collection processing and storage or autologous blood, special pump services 
and washed white blood cells.. You say that you would like reconsideration based on the records submitted. 
The Plan denied your request. The Plan says payment for these services is included in the payment to the 
facility. 
 
The Plan must follow Medicare rules. Medicare rules say that all items and non-physician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the collection processing and storage or autologous blood, special pump services and washed white 
blood cells. have not been met. Specifically, the record shows that the member was registered inpatient on the 
billed date of service. Payment for these services is included in the payment to the facility and is the 
responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the 
collection processing and storage of autologous blood (86891), special pump services (99190 and 99191) and 
washed red blood cells (P9022) provided on July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on April 23, 
2021. 
 
You asked the Plan to pay for the special anesthesia service. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says CPT code 99100 has a status indicator 
of B. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 
 
  
We find that CPT code 99100 is not supported in the record. Specifically, CPT code 99100 has a status 
indicator of B. This means that the payment for CPT code 99100 is always bundled into the payment for 
another service or procedure. Based on this information, we decided that Medicare rules for coverage of the 
special anesthesia service have not been met. Therefore, we decided that the Plan does not have to pay for the 
special anesthesia service (99100) provided on April 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on September 12, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the provider is in-network. The Plan denied your 
request. The Plan says no prior authorization was obtained. 
 
 
 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 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 office visit provided on September 12, 2021, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital bed, fixed height, without side rails, with 
mattress (E0290) unlisted special service, procedure or report (99199) provided October 8, 2020 to December 
6, 2020. 
 
You asked the Plan to pay for the hospital bed. You say that central to your recovery was a hospital bed you 
rented. When you came home from the hospital and nursing home you could not walk at all. The Plan denied 
your request. The Plan says this provider is not certified for Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the hospital bed, fixed height, without 
side rails, with mattress (E0290) unlisted special service, procedure or report (99199) provided October 8, 2020 
to December 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital bed provided on January 6, 2021, through May 
5, 2021. 
 
You asked the Plan to pay for the hospital bed. You say that the service should be covered. The Plan denied 
your request. The Plan says you obtained this item through a provider that is not certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the hospital bed provided on January 6, 
2021, through May 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 11, 2021 to 
August 25, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on August 11, 2021 to August 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says based on Medicare 
guidelines, the IRF services you and/or your provider are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the documentation does not support that the complexity of the enrollee's nursing, 
medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The documentation does not support that the enrollee requires at least 3 hours a day for 5 days a week, or 15 hours over 7 consecutive days, of therapy services. It is unclear whether the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
Services 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Lymphapress chambered pneumatic compression 
device (E0651, E0667) for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that you are exclusive providers for this device. The 
Plan denied your request. The Plan says the services are available in the plan's network. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found based on the provided office visit records, there is no documentation that the enrollee has tried and 
failed a lymphedema pump from an in-network provider to indicate necessity for the requested out-of-
network Lymphapress brand chambered pneumatic compression device (E0651, E0667). 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Lymphapress chambered pneumatic compression device (E0651, E0667) for the enrollee.
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 enrollee's records do not show that they need daily inpatient skilled therapy. 
The Plan states the services they require can safely be received at a different setting, for example, home with 
home health, in residential care, or home with close follow-up with the enrollee's doctor. 
 
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 there are no identifiable skilled nursing 
service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing 
or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria 
for an inpatient basis in a SNF setting. 
 
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 Xeomin for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this request is not Food and Drug Administration (FDA) approved for treatment of 
spasms of the lower extremities. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the reviewed 
documentation indicates that the enrollee is currently taking this medication for lower extremity muscle spasm. 
This medication is not approved by the FDA for the use of lower limb muscle spasms. In 2016, 
onabotulinumtoxinA ( Xeomin) was approved to decrease the severity of muscle stiffness in adults with lower-
limb spasticity. IncobotulinumtoxinA (Xeomin) is another BoNT-A drug, which received a new indication in 
2015 for the treatment of patients with upper-limb spasticity. The documentation does not support that the 
Xeomin is safe and effective 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Xeomin for the enrollee.
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 limited available information indicates that the enrollee does not require this 
SNF admission as they have already been approved for admission to a different skilled nursing facility and the 
enrollee is already discharged from the hospital. 
 
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 there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled 
nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a SNF setting. 
 
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 the Guardant360 testing (0242U) provided on July 15, 2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration because 
this claim was billed correctly. The Plan denied your request. The Plan says this claim was not billed with the 
appropriate place of service code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
  
We find that CPT code 0242U is not supported in the record. Specifically, this claim was billed with the 
laboratory place of service code while the records suggest the member's face-to-face service was rendered in an 
office setting. Based on this information, we decided that Medicare rules for coverage of the Guardant360 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing 
(0242U) provided on July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the limited bilateral noninvasive 
physiologic studies of upper or lower extremity arteries (93922) provided on October 6, 2021. 
 
You asked the Plan to waive the deductible. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the deductible has been applied correctly to 
the service provided. 
 
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 a $200 
annual deductible. This is the amount you have to pay out-of-pocket before the plan will pay its share for your 
covered Medicare Part A and B services.   
 You have been asked to pay $45.19 as you had not previously met the annual deductible. This is the Plans 
allowed amount for this service. 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 deductible for the limited bilateral 
noninvasive physiologic studies of upper or lower extremity arteries (93922) provided on October 6, 2021.