Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (POC). 
 You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no medical documentation to support the need for this concentrator. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
To qualify for home oxygen, the patient must meet one of the following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep;  
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, 
there is a rebuttable presumption of non-coverage. 
 
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 concentrator. Our reviewer says that 
the requested concentrator is not medically reasonable or necessary. Our physician reviewer found you have 
severe obesity, obstructive sleep apnea, and pulmonary hypertension. Spirometry is also consistent with mild 
chronic obstructive pulmonary disease (COPD). The records do not document that you are currently on oxygen 
supplementation, and do not include information that meets Medicare criteria for either supplemental oxygen or 
a POC. 
 
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 concentrator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a portable oxygen concentrator (POC).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya.
You asked the Plan to pre-approve Ilumya. You say that this drug is medically reasonable and necessary. The Plan denied your request. The Plan says step therapy criteria have not been met.
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 Ilumya. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of Humira, Enbrel, or Skyrizi before they will approve the requested drug. In this case, the patient has not tried and failed the required drug(s). There is no documentation provided indicating 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 Ilumya have not been met. Therefore, we decided that the Plan does not have to pre-approve Ilumya.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the external mobile cardiovascular telemetry with electrocardiographic recording (93228 and 93229).
You asked the Plan to pre-approve the external mobile cardiovascular telemetry with electrocardiographic recording. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
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 external mobile cardiovascular telemetry with electrocardiographic recording. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is insufficient documentation to support the medical necessity for an MCOT monitor in this patient's clinical management.
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 external mobile cardiovascular telemetry with electrocardiographic recording have not been met. Therefore, we decided that the Plan does not have to pre-approve the external mobile cardiovascular telemetry with electrocardiographic recording (93228 and 93229).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request. 
The Plan says rules for IRF care have not been met. 
 
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 the review has determined that the complexity of the patient's nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable 
expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit (G0439) provided on September 15, 2021.
You asked the Plan to pay for the annual wellness visit (G0439). You say that you were hospitalized and seen
multiple specialist due to fainting. You say that you would not be receiving this bill from the provider if they
billed it timely and you should not be responsible for the billing of this doctor. The Plan denied your request.
The Plan says this amount will not be covered because you have already received the maximum amount of coverage allowed for this type of service.
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months.
Based on review of the file, an AWV was provided within 12 of the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for the annual wellness visit (G0439) provided on September 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for removal of non-cancerous growth received on May 13, 2021. 
 
You asked the Plan to pay for the services. You say that you would like full reimbursement. The Plan denied 
your request. The Plan says balance billing is not allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers may not balance bill enrollees.  
 
 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. The provider is balance billing you. However, it does appear that 
they have reimbursed you $203.47, and the plan has paid the provider the contract amount for the services. 
Further reimbursement cannot be made. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay further 
for removal of non-cancerous growth received on May 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on March 18, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the requested service code is not substantiated by the clinical documentation in the operative 
report. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 50715 
is a column II code to column I code 44146. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for surgical services provided to the enrollee on March 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing (0242U) provided on July 28, 2021.
You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim was not billed with the correct place of service code.
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Guardant360 testing have not been met. Specifically, this claim was billed with the laboratory place of service code while the records suggest that the member's face-to-face service was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing (0242U) provided on July 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 31, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a
physician who has furnished a consultation or treats an enrollee for a specific medical problem.
We looked at the file and Medicare rules. The file does not contain documentation of an established
relationship between the enrollee and the ordering provider. Without a record showing that this provider is
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the
Plan does not have to pay for the laboratory services rendered on July 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.
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 based on the documentation provided the enrollee does not require the intensity of
services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that there is a lack of need for intensity of services. The Plan denied your request. The Plan says the enrollee is currently unstable for transfer.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our physician reviewer found that the enrollee presented to the acute care hospital with acute hypoxic respiratory failure. The prognosis remains guarded. The enrollee is noted to be critically ill. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 8, 2021 to
September 22, 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 covered.
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 endstage
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 September 8, 2021 to September 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 7, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on April 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient level of care for the approved total knee 
arthroplasty. 
 
You asked the Plan to pre-approve an inpatient level of care. You say that the requested inpatient level of care 
for the approved total knee arthroplasty is medically necessary. The Plan denied your request. The Plan says 
the requested inpatient level of care for the approved total knee arthroplasty is not medically necessary. 
 
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 inpatient level of care. Our reviewer says that the requested inpatient level of care for the approved total knee arthroplasty is not medically 
necessary. Our physician reviewer found the record indicates that the enrollee is scheduled for a total knee 
arthroplasty.  The record does not document that the treating physician has a reasonable expectation of a length 
of stay spanning 2 or more midnights. The enrollee may be admitted for observation.  The elements of the 
coverage rule are not satisfied.  The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient level of care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an inpatient level of care for the approved total knee arthroplasty.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiologic examination, spine, lumbosacral (72100) provided October 5, 2021.
You asked the Plan to pay for the diagnostic service. You say that you fell walking and to verify that your hip replacement was not broken or chipped, you went to your chiropractor. He was careful not to give you an adjustment until he took x-rays of the wound. The Plan denied your request. The Plan says this service is not covered when rendered by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the radiologic examination, spine, lumbosacral (72100) provided October 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a root canal (D3330), crown (D2750), and core build up
(D2950) to be provided by an out of network provider.
You asked the Plan to pre-approve the dental services. You say that you were not able to find an in network
provider. The Plan denied your request. The Plan says the provider in this case is not in network. The Plan also
says dental services are not covered out of network.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested dental services are not among those covered under this benefit when received by an out of network provider. Therefore, we decided that the Plan does not have to pre-approve a root canal (D3330), crown (D2750), and core build up (D2950) to be provided by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not 
require at least 3 hours a day/5 days a week, or 15 hours over 7 consecutive days, of therapy services. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sclerotherapy. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says the available documentation shows that most veins are smaller than 4mm in 
diameter, and there is reflux in multiple veins. 
 
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 procedure. 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 previously undergone saphenous ablation for reflux. 
The provided records do not include a recent ultrasound documenting the absence of saphenous reflux and the 
persistence of tributaries greater than 4 mm in diameter and refractory to conservative treatment. 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sclerotherapy.