Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on 
June 8, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for 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 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 out of network medical services provided to the enrollee on June 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telehealth services provided on February 6, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the telehealth 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 telehealth 
services are not covered when provided by an out-of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that telehealth services are not covered when provided by an out-of-network provider. 
 
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 telehealth 
services provided on February 6, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services coded as 93010 and 99291 provided on 
September 20, 2020. 
 
You asked the Plan to pay for the medical services. You say that you would like these claims reprocessed and 
approved for payment. The Plan denied your request. The Plan says they have insufficient documentation to 
corroborate the services provided. 
 
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 codes 93010 and 99291 is not supported in the medical record. Specifically, the medical 
records provided are insufficient to corroborate the services received. There is no mention of either of the 
procedures in the documentation provided.  
 
Based on this information, we decided that Medicare rules for coverage of the medical services have not been 
met. Therefore, we decided that the Plan does not have to pay for the medical services coded as 93010 and 
99291 provided on September 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ConfirmMDx testing provided on June 7, 2021.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says a repeat biopsy
was not being considered due to elevated risk factors.
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 pay for the testing services. Our physician reviewer
found that the enrollee has an elevated PSA of 12.3 ng/mL. He was evaluated with ultrasound guided needle
biopsy. The pathology was all benign. The records do not show that ConfirmMDx testing was indicated for the
enrollee's condition. A repeat biopsy was not being considered due to elevated risk factors. Also, the enrollee
was not between 40 to 85 years old. Based on the rules and records, the ConfirmMDx testing was no medically
reasonable 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 testing services have not been met. Therefore, we decided that the Plan does
not have to pay for the ConfirmMDx testing provided on June 7, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on July 
29, 2020. 
 
You asked the Plan to pay for code 99309. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that the provider billed duplicate 
claims per Medicare guidelines. The claims have both the beneficiary identifier, provider number, date of 
service, type of service, procedure code, place of service and billed amount. Therefore, we decided that the 
Plan does not have to pay for the subsequent nursing facility care (99309) provided on July 29, 2020.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the member's medical and therapy needs could be met in a skilled 
nursing unit. 
 
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. 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 was admitted for respiratory failure 
and congestive heart failure. The enrollee's medical problems are stable. There are no complex nursing or 
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation 
does support a need for physical and/or occupational therapy, there is no documented need for an intensive, 
multi-disciplinary rehabilitation 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. Our 
physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp for the enrollee.
You asked the Plan to pre-approve Aranesp. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the patient does not have trial and failure or history of intolerance or adverse event to Retacrit.
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 Aranesp. Our reviewer says that
Aranesp is not medically reasonable and necessary for the enrollee in this case. The patient has not tried and
failed Retacrit. There is no documentation provided indicating that Retacrit would likely be less effective
and/or likely have adverse effects for the enrollee. Our physician reviewer found that the enrollee's condition
does not meet step therapy criteria for Aranesp.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have
to pre-approve Aranesp for the enrollee
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 this is medically necessary. The Plan 
denied your request. The Plan says once you are ready to leave the hospital, you can safely receive this care in 
a different setting, such as a skilled nursing or home with home health services. 
 
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 reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided indicating medical necessity for admission to a 
LTACH. You are receiving appropriate care at the present acute care hospital. You do 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 you require that are not available at the health care setting being offered 
by the health plan. The requested LTACH services medically necessary, reasonable, and appropriate for the 
diagnosis and your condition and able to be furnished safely and effectively only on an inpatient basis. 
 
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: 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 the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the documentation does support a need for physical and/or occupational 
therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment purchased on May 12, 2021.
You asked the Plan to pay for durable medical equipment purchased from a retail provider. You say that these items should be covered by the Plan. The Plan denied your request. The Plan says durable medical equipment requires prior authorization, and these items were not purchased from an eligible Medicare provider.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a provider who is not a Medicare eligible provider. The retailer this equipment was purchased from is not a Medicare eligible provider. You did not have prior authorization for this equipment. Therefore, we decided that the Plan does not have to pay for durable medical equipment purchased from Amazon.com on May 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for out of network podiatry services.  
 
You asked the Plan to provide coverage for out of network podiatry services. You say that the enrollee prefers 
to see the requested provider because the podiatry services required cannot be provided in network. The Plan 
denied your request. The Plan says this treatment can be provided in network and the recommended provider 
has confirmed this.  
 
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 provider in this case is not a network provider with the Plan. 
The Plan has network providers who can render this treatment. Therefore, we decided that the Plan does not 
have to provide coverage for out of network podiatry services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthrodesis of the sacroiliac joint (27279) with fluoroscopic guidance (77003).
You asked the Plan to pre-approve arthrodesis of the sacroiliac joint with fluoroscopic guidance. You say that the Plan denial is based on the wrong diagnosis. The Plan denied your request. The Plan says medical necessity rules for the requested services have not been met.
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 arthrodesis of the sacroiliac joint with
fluoroscopic guidance. Our reviewer says that the requested services are not considered medically reasonable
and necessary in this case.
Our physician reviewer found that you have a diagnosis of sacroilitis. You received sacroiliac joint injections
from a prior physician, but those records are not submitted for review. There is no imaging supporting the
diagnosis. There is no documentation of bracing or physical therapy. Your Oswesty Disability index is less
than 30. You do not meet standard criteria for a surgical intervention.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of arthrodesis of the sacroiliac joint with fluoroscopic guidance have not been met.
Therefore, we decided that the Plan does not have to pre-approve arthrodesis of the sacroiliac joint (27279)
with fluoroscopic guidance (77003).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit (99213) to be provided by an out-of-network provider.
You asked the Plan to pre-approve the out-of-network office visit. You say that the services are medically necessary. The Plan denied your request. The Plan says there are network providers available.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office visit (99213) to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Purewick Urine Collection System. 
 
You asked the Plan to pre-approve a Purewick Urine Collection System. You say that the items are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 a Purewick Urine Collection System. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the requested Purewick Urine Collection System is not furnished in a 
setting appropriate to your medical needs and condition. The documentation does not reveal objective evidence 
that you require this device for urination. There is no objective evidence that you are unable to transfer to a 
toilet or use intermittent self-catheterization. You are requesting a raised toilet seat as well. The documentation 
does not clearly support the need for this request. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Purewick Urine Collection System have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Purewick Urine Collection System.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667) for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of truncal edema.
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 the record indicates that the enrollee has lymphedema of the lower extremities. The record does not indicate that the enrollee has truncal edema. The elements of the coverage criteria 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the vitamin injections (J3490, J3411, J3415, and J1955) 
provided on August 24, 2020. 
 
You asked the Plan to pay for the vitamin injections. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the vitamin injections have not been met. Specifically, the multiple drug codes reported on this 
claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be 
billed using the NOC code J7999. As this compounded drug was not billed properly, payment cannot be made. 
Therefore, we decided that the Plan does not have to pay for the vitamin injections (J3490, J3411, J3415, and 
J1955) provided on August 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient Gastroenterology office visit to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that you were advised by your doctors there there 
are no other FDA approved drugs for your illness and no other procedure that will alleviate your symptoms. 
The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network 
provider with the exception being urgent or emergent services. Non-emergent services with non-contracted 
providers require prior authorization before services being rendered. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the outpatient Gastroenterology office visit to be provided by an out-of-network (OON) provider.