Persius/hicric huggingface dataset:
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 you were admitted for surgical repair of a distal femur fracture after a fall. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that you 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry and tandem mass spectrometry 
services provided on January 18, 2022.  
You asked the Plan to pay for the mass spectrometry and tandem mass spectrometry service. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not a covered 
benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The documentation shows that no medical records were provided. No medical records were provided to support 
this testing provided. This means the documentation does not support that the test at issue in this appeal was 
not requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. 
Therefore, we decided that the Plan does not have to pay for the mass spectrometry and tandem mass 
spectrometry services provided on January 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durvalumab injections. 
 
You asked the Plan to pre-approve Durvalumab injections. 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 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 Durvalumab injections have been met. 
Specifically, medical records were not received. Attempts to reach the provider were unsuccessful. Without this 
information, medical necessity is not able to be established. Therefore, we decided that the Plan does not have 
to pre-approve Durvalumab injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services rendered on July 1, 2022. 
 
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 the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The contract with the Plan states that 30 additional 
visits are covered for additional chiropratic services. 
 
The file shows that the enrollee received additional chiropractic services on July 1, 2022. The enrollee reached 
the 30 visit limit on May 11, 2022. The services on July 1, 2022 are not covered by the enrollee's medical 
benefit or the Plan supplemental benefit. Therefore, we decided that the Plan does not have to pay for the 
chiropractic services rendered on July 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pain management services provided on May 12, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the pain management services. You say that the Plan has paid previous claims for 
this patient. The Plan denied your request. The Plan says unauthorized, out-of-network care is not covered.  
Further, the Plan says that any past payments may have been paid incorrectly and may be subject to 
recoupment. 
 
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 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 pain management services provided on May 12, 2022, by an out-
of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair. 
 
You asked the Plan to pre-approve a wheelchair. You say that the item is necessary. The Plan denied your 
request. The Plan says the enrollee resides in a skilled nursing facility. Therefore, the item is not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a wheelchair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. 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 must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Keytruda. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the Food and Drug Administration has not 
stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug 
compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation. No literature from Medicare approved cancer journals were submitted for review. 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for needle electromyography services (procedure codes 51785, 95861) 
provided to the enrollee on May 6, 2022. 
 
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 that the denied codes remain 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 
the denied codes is: 
 
CPT 51785: 
 
Needle electromyography studies (EMG) of anal or urethral sphincter, any technique 
 
CPT 95861: 
 
Needle electromyography; 2 extremities with or without related paraspinal areas 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the neurodiagnostic report 
documented that Subdermal electrodes were placed in the anal sphincter to monitor electromyographic (EMG) 
responses during the procedure. Therefore, the records do support that CPT 51785: Needle electromyography 
studies (EMG) of anal or urethral sphincter, any technique was rendered in this case. Additionally, 
neurodiagnostic report documented that Subdermal needle electrodes were placed in the corresponding 
myotomes in relation to the operative levels bilaterally and no spontaneous electromyographic (EMG) activity 
was observed at baseline. Therefore, the records do support that CPT 95861: Needle electromyography; 2 
extremities with or without related paraspinal areas were rendered in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
needle electromyography services (procedure codes 51785, 95861) provided to the enrollee on May 6, 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 pay for the motorized scooter you purchased on June 24, 2022. 
 
You asked the Plan to pay for the motorized scooter. You say that no one told you that you had to use a 
Medicare-participating provider in order to be reimbursed. The Plan denied your request. The Plan says you 
purchased this item from an ineligible provider. 
 
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 
motorized scooter you purchased on June 24, 2022.
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 services 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. 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 you have functional impairments and an IRF 
compliant diagnosis since you are greater than age 85 however, there are no specified active comorbidities. Thus, you would not be expected to require close medical monitoring on an inpatient basis 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal x-ray (74018) provided on February 18, 2022. 
 
You asked the Plan to pay for the x-ray. You say that the service should be covered. 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 11, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the abdominal x-ray 
(74018) provided on February 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitoring (CGM) system and 
supplies. 
 
You asked the Plan to pre-approve a CGM system and supplies. 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 must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM system and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a continuous glucose monitoring (CGM) system and supplies.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 70498 billed for date of service June 19, 2021. 
 
You asked the Plan to pay for code 90498. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and 
was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on November 26, 2021. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for code 90498 have not been met. Therefore, 
we decided that the Plan does not have to pay for code 70498 billed for date of service June 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 7, 2021 billed with 
codes 81275, 81235, 81210, and 81206. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
December 7, 2021 billed with codes 81275, 81235, 81210, and 81206.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay further for the transportation rendered on June 27, 2022. 
 
You asked the Plan to pay further for these services. You say that you received less reimbursement than you 
believed it should be. The Plan denied your request. The Plan says the claim was processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that kidney, heart, lung, heart/lung, liver, pancreas, 
pancreas/kidney, and intestinal/multi-visceral organ transplants are covered. The contract with the Plan states 
that appropriate transportation costs will be arranged for transplant services outside of your community of 
providers. 
 
We looked at the file, Medicare rules, and the Plans rules. The file shows that you had transportation costs to 
and from a transplant facility for a total of 292 miles round-trip. The Plan reimbursed these services at 18 cents 
per mile. Further reimbursement is not covered by Medicare or the Plans supplemental benefit.  Therefore, we 
decided that the Plan does not have to pay further for the transportation rendered on June 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share amount for the office visit (99213) provided on 
July 11, 2022. 
 
You asked the Plan to waive the cost share amount for the outpatient service. You say that the provider is 
billing you $354.60 for the knee injection you received on the date of service in this case. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
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 $5 
copayment for Physician Specialist Services.  
 
You have been asked to pay a $5 copayment for the outpatient service. This service falls within the Physician 
Specialist Services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the cost share amount for the office 
visit (99213) provided on July 11, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from December 13, 2021, 
to January 11, 2022. 
 
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 claims were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that a RAP and a claim must be submitted for all episodes 
for which Medicare makes payment based on HIPPS codes. 
 
We looked at the file and Medicare rules. The file shows that the claims were not submitted with the required 
RAP. 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 pay for the home health services rendered from 
December 13, 2021, to January 11, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
February 7, 2022. 
 
You asked the Plan to pay for the nursing facility care. You say that the service was medically necessary. 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 subsequent nursing facility care (99308) provided on 
February 7, 2022.