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 you do not have anyone at home to take care of you 
and you are a high risk for falling. The Plan denied your request. The Plan says your records do not show you 
need and are able to take part in 3 hours of therapy a day at least 5 days a week or 15 hours per week, services 
you need can be provided safely in other settings, a skilled nursing facility, home with home health services or 
home with outpatient therapy. 
 
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 needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gamunex-C. 
 
You asked the Plan to pre-approve Gamunex-C. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says this drug is being dispensed by a pharmacy and is not eligible for coverage under 
the Part B medical benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Gamunex-C.  
 
Benefits for Gamunex-C may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SSBCI benefits. 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you believe you are eligible for the SSBCI 
benefits. The Plan denied your request. The Plan says you do not meet the criteria to be eligible for SSBCI 
benefits. 
 
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. The Plan requested medical records from your provider but did not 
receive any, and without medical records we cannot determine whether you meet the criteria for the SSBCI 
benefits. Based on this information, we decided that there is insufficient information in the record to determine 
if Medicare rules for coverage of the SSBCI benefits have been met. Therefore, we decided that the Plan does 
not have to pre-approve the SSBCI benefits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit (99344) and urinalysis (81002) provided on 
August 10, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the home visit (99344) and urinalysis (81002) provided on 
August 10, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing (81203, 81408, 81162, 81406, 81404, 
81403, 81242, 81404, 81294, 81297, 81300, 81401, 81408, 81406, 81319, 81323, 81404, 81405, 81404, 81404, 
81403) provided on July 13, 2022. 
 
You asked the Plan to pay for the laboratory testing. You say that this claim should be covered. The Plan 
denied your request. The Plan says additional information was needed to review this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 the laboratory testing have been met. In this case the Plan requested a physician order, lab requisition and/or office visit notes and medical records 
that show the intent for testing. This information was not provided. Without this information we are unable to 
verify whether the testing provided was medically reasonable and necessary and meets Medicare criteria for 
coverage. Therefore, we decided that the Plan does not have to pay for the laboratory testing (81203, 81408, 
81162, 81406, 81404, 81403, 81242, 81404, 81294, 81297, 81300, 81401, 81408, 81406, 81319, 81323, 81404, 
81405, 81404, 81404, 81403) provided on July 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 29, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the open treatment of femoral fracture, proximal end, neck, 
internal fixation or prosthetic replacement (27236) provided on April 6, 2022. 
 
You asked the Plan to pay for the surgical service. You say that the service was medically necessary. The Plan 
denied your request. The Plan says a certified surgical first assistant (CSFA) is not eligible to receive payment. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the open treatment of femoral 
fracture, proximal end, neck, internal fixation or prosthetic replacement (27236) provided on April 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator, any type, used with non-invasive 
interface (E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that a home bilevel positive airway pressure (BiPap) 
has been considered and ruled out. This enrollee needs this equipment. The Plan denied your request. The Plan 
says the device to assist with breathing (noninvasive ventilator) requested does not meet the requirements for 
approval. 
 
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 the ventilator. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this enrollee was hospitalized in October 2022 with pneumonia, and arterial blood gas (ABG) 
showed a partial pressure of carbon dioxide (PaCO2) of 70 with a normal pulmonary hypertension (pH). The enrollee has severe obesity and has a diagnosis of obesity hypoventilation syndrome.  Chronic obstructive 
pulmonary disease (COPD) was suspected, although no pulmonary function testing is available.  A chest 
computed tomography (CT) mentions emphysema.  The enrollee improved in the hospital with BiPAP.  There 
is no ABG done while stable to document chronic carbon dioxide (CO2) retention.  If this enrollee does have 
chronic CO2 retention, may benefit from BiPAP during sleep as an outpatient.  If the enrollee does have 
significant COPD, the average volume assured pressure support (AVAPS) mode can be provided with BiPAP.  
Medicare does not cover a home ventilator when used at settings that can be provided with BiPAP.  A home 
ventilator is not 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 the ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the home ventilator, any type, used with non-invasive interface (E0466).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neulasta (J2506). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 the medication. Our physician reviewer 
found the record indicates that the enrollee has a diagnosis of Acute myeloblastic leukemia and Neutropenia, 
unspecified. The underlying condition is a myeloid malignancy. 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Neulasta (J2506).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine (90750) provided on December 8, 2022. 
 
You asked the Plan to pay for the vaccine. You say that you have received shingles vaccines in the past during 
annual physicals. You also say that you have never been charged for this in the past. The Plan denied your 
request. The Plan says the vaccine in this case is not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine. 
Therefore, we decided that the Plan does not have to pay for the shingles vaccine (90750) provided on 
December 8, 2022.  
 
Benefits for the vaccine may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency department visit provided on 
July 16, 2022. 
 
You asked the Plan to waive the copayment for the emergency department visit. 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 $120 
copayment for emergency care.  
 
You have been asked to pay a $120 copayment for the emergency department visit. This service falls within the 
emergency care 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 copayment for an emergency department 
visit provided on July 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98940) provided on 
October 25, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service provided is considered 
maintenance therapy, which is not a Medicare-covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 this service. Our reviewer says that the 
service provided does not meet criteria for coverage. Our physician reviewer found that in this case, the record 
indicates that you have a spinal subluxation. The records indicate that the service provided was considered 
maintenance therapy. 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pay for the chiropractic manipulative treatment (98940) provided on October 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that the item is medically necessary. The Plan denied your 
request. The Plan says you do not use insulin with at least three daily injections. 
 
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 have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the TEN urinary tract infection (UTI) panel provided on July 
25, 2022. 
 
You asked the Plan to pay for the TEN UTI panel. You say that this is a medically necessary, Medicare-
covered test. The Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that this testing requires registration with MolDX and 
a TA to demonstrate compliance with the LCD policy. 
 
We looked at the file and Medicare rules. In this case the requested testing does not have an approved TA on 
file. Based on this information, we decided that Medicare rules for coverage of the TEN UTI panel have not 
been met. Therefore, we decided that the Plan does not have to pay for the TEN urinary tract infection (UTI) 
panel provided on July 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight Psychotropic Assay (81479) provided on May 7, 
2022. 
 You asked the Plan to pay for genetic testing. You say that this service was denied in error and should be paid 
as a covered benefit. The Plan denied your request. The Plan says the requested testing reported on May 11, 
2022, remains denied based on lack of medical necessity for the service 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medications listed for consideration for dosage adjustment included 
Cymbalta (duloxetine). Though the order stated that the member had failed treatment with several medications 
and that several medications were being considered for augmentation or starting/switching to and dosage 
adjustment, there is no documentation of such provided in the medical records. The LCD states, The selection 
of the medications in question must be derived from clinical factors/necessity rather than from a 
pharmacogenetic test. Pharmacogenetic testing is not considered reasonable and necessary merely on the basis 
of a patient having a particular diagnosis. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
GeneSight Psychotropic Assay (81479) provided on May 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mastectomy bra (L8000) and silicone or equal, without 
integral adhesive (L8030) provided on August 30, 2022. 
 
You asked the Plan to pay for the mastectomy bra and silicone or equal, without integral adhesive. The Plan 
denied your request. The Plan says the provider billed for services and there is no record proof of delivery for 
this service. The Plan also says the medical records submitted do not contain the above-listed information. 
 
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 for the supplies provided in this case. 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 mastectomy bra (L8000) and silicone or equal, without 
integral adhesive (L8030) provided on August 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 2, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 2, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan. 
 
You asked the Plan to pre-approve a computed tomography (CT) scan. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says that the criteria for 
approval have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a computed tomography (CT) scan. Our 
reviewer says that the service is medically necessary. Our physician reviewer found the patient has known 
metastatic anal carcinoma and their carcinoembryonic antigen (CEA) spiked in November 2022. Anal 
carcinoma is known to have a propensity for chest metastases to the chest due to lymph channel connection. 
The increase in CEA is worrisome for metastatic disease and close surveillance of the chest is in order due to 
the increase in CEA, 
 
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 computed tomography (CT) scan have been met. Therefore, we decided that 
the Plan has to pre-approve a computed tomography (CT) scan.  
 
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.