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

 
We decided that the Plan does not have to pay for the radiology services provided on January 27, 2022. 
 
You asked the Plan to pay for the radiology services. You say that the services were billed correctly. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the radiology services provided on January 27, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient psychiatric services provided by Hendricks Behavioral 
Hospital on June 4, 2022, to June 15, 2022. 
 
You asked the Plan to pay for inpatient psychiatric hospital services. You say that these services were 
medically necessary. The Plan denied your request. The Plan says that services beyond June 14, 2022, were not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. Our 
reviewer says that these inpatient psychiatric services are medically necessary. Our physician reviewer found 
the enrollee meets the criteria for inpatient mental health treatment services beyond June 14, 2022. 
 
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 psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pay for inpatient psychiatric services provided by Hendricks Behavioral Hospital on June 4, 
2022, to June 15, 2022.  
 
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 a manual wheelchair and accessories. 
 
You asked the Plan to pre-approve a manual wheelchair and accessories. You say that the items are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a manual wheelchair and accessories 
have been met. Medical records were requested but not received. Medical necessity is not able to be established 
without this documentation. Therefore, we decided that the Plan does not have to pre-approve a manual 
wheelchair and accessories.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 31, 2022. 
 
You asked the Plan to pay for the billed services. You say that the low payment does not cover the expense of 
the enrollee's treatment. The Plan denied your request. The Plan says the codes are not eligible for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT codes 80053, 81002, and 85025 are not payable under the physician fee schedule. Based on 
this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on May 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies, 2 lead, per month (A4595) 
provided April 28, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that the claim was billed in accordance 
with the enrollee's Plan policy allowable, accepted procedure codes and diagnosis codes according to Pan type. 
The Plan denied your request. The Plan says evidence of misrepresented services. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. Specifically, the delivery ticket submitted did include the 
carrier's tracking number, although tracking is unable to be verified with USPS as of September 7, 2022 
tracking only shows label created but not in system. The proof of delivery did not include an order number or 
details to corroborate the delivery ticket submitted. Of note, the proof of delivery is not itemized to indicate the 
specific supplies. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the electrical stimulator supplies, 
2 lead, per month (A4595) provided April 28, 2022.
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 this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the enrollee does not meet medical necessity for SNF admission based 
on Medicare criteria for coverage guidelines. 
 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found The enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine. 
 
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the 
enrollee. The Plan denied your request. The Plan says this service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 this service. Our reviewer says that this 
service is not medically necessary. Our physician reviewer found that in this case the record indicates that the 
enrollee has cognitive impairment. The record does not indicate the presence of any thoracic complaints or 
pathology or that the provider intended to order the requested study. The elements of the coverage criteria are 
not satisfied. The requested service cannot be 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found you have chronic respiratory failure 
from chronic obstructive pulmonary disease (COPD). The record indicates that the provider intended to order 
bi-level positive airway pressure (BiPAP) therapy. The provided primary source documentation does not 
contain sufficient detailed information in the medical record to justify the treatment selected. The criteria for 
coverage are not met and the home ventilator is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a left atrial appendage closure (LAAC) 
device. 
 You asked the Plan to pre-approve placement of a LAAC device. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that LAAC devices are covered when the device has 
received Food and Drug Administration (FDA) Premarket Approval (PMA) for that devices FDA-approved 
indication and meet specific criteria. 
 
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 placement of a LAAC device. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found there is no 
contraindication to anticoagulation according to the physician. As such, guidelines would not support 
implantation of a LAAC in this setting. In summary, LAAC placement would not be considered reasonable or 
medically necessary in this enrollees 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 placement of a LAAC device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of a left atrial appendage closure (LAAC) device.
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 enrollee does not meet criteria for IRF admission. 
 
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 clinical documentation shows that the enrollee has functional impairments, but there 
is no documented IRF compliant diagnosis or complexity of deficits that would warrant intense therapy or interdisciplinary team management. Additionally, evaluating therapists recommends therapy 4 days per week 
in treatment notes. Clinical documentation states that medical issues are stable thus would not be expected to 
require continued inpatient hospitalization during rehabilitation. 
 
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 acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee had to have bypass surgery and is now 
focusing on recovery. The enrollee is weaker than normal and lives alone, so their doctor feels it dangerous to 
go home and recommends the enrollee has rehab. The Plan denied your request. The Plan says the request is 
not medically necessary, the services the enrollee needs can be provided safely in other settings. 
 
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 enrollees medical problems are stable and there are no complex nursing or rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary 
care can be provided in a different 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 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 a skilled nursing facility is not able to 
meet the enrollee's needs. The Plan denied your request. The Plan says criteria for admission to the LTACH 
have not been met. 
 
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 that the enrollee is receiving appropriate care at the present acute care hospital. 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 Plan. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits, pathology, and biopsy's (99214, 88305, 
99243, 11102, 11104, 11106, 99202, 99203, 99204) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits, pathology, and biopsy's. You say that you need a non-surgical 
removal because you have had previous procedures in the area and part of your nose was removed. You have 
another skin cancer that needs to be removed directly above the area where a part of your nose was previously 
removed. You waited a week with a giant hole in your face to have plastic surgery of your nose. You also say 
you would like to see the requested provider because they are the only ones who can do a non-surgical skin 
cancer removal. The Plan denied your request. The Plan says you must use network providers to get your 
medical care and services. The Plan also says there are providers available in network. 
 
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 
office visits, pathology, and biopsy's (99214, 88305, 99243, 11102, 11104, 11106, 99202, 99203, 99204) to be 
provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (G0483) provided on April 21, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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, the CPT Code Manual definition of code G0483 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed".  
We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not show that 
22 or more drug classes were tested on the date of service in question. 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 for the drug testing services (G0483) provided on April 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc (J7325). 
 
You asked the Plan to pre-approve Synvisc. You say that the requested drug is necessary for the enrollee. The 
Plan denied your request. The Plan says the enrollee has not tried and failed one of the preferred drugs, 
Orthovisc or Supartz FX. 
 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 Synvisc. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed one of the plan's preferred drugs. The reviewer also found that there is no 
indication that the plan's required drugs would likely be less effective and/or likely have adverse effects for the 
enrollee. Therefore, the reviewer found that the step therapy 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 Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc (J7325).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on April 6, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that there is no agreement that the codes billed 
are included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay 
for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate.  
 No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services related to end-stage renal disease (ESRD) provided on April 6, 2022.