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

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging (MPI) for the enrollee. 
 
You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your 
request. The Plan says the notes do not show why a routine exercise stress test cannot be done instead. 
 
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 imaging. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that at issue is the medical appropriateness and necessity of carrying out a radionuclide stress 
test in this patient with chest pain. There is no documentation that the ECG shows an uninterpretable pattern. 
There is no evidence provided that would support the need for radionuclide stress testing. In summary, there is 
insufficient documentation to support the medical necessity for the requested cardiac stress testing in this 
patients clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the imaging have not been met. Therefore, we decided that the Plan does not 
have to pre-approve myocardial perfusion imaging (MPI) for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy visits to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the physical therapy visits. You say that there are no in-network providers 
that can provide the services that the enrollee's needs. The Plan denied your request. The Plan says the 
requested provider is an OON provider, and it was confirmed that there are in-network providers that can 
provide the requested service that the enrollee needs. Also, the service requested is not urgent or emergent. 
 
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 
physical therapy visits to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve the portable oxygen concentrator. You say that the oxygen tank you have is 
heavy and next to your bed while the other tank is a tube with wheels, but it is also too heavy. The Plan denied 
your request. The Plan says the records do not support that the enrollee meets the criteria for the portable 
oxygen concentrator and related equipment. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 portable oxygen concentrator Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this enrollee has a diagnosis of prostate cancer. There is no diagnosis that 
would necessitate supplemental oxygen, other than a history of a pleural effusion, and the medical records 
provided make no mention of a requirement for supplemental oxygen. Oxygen saturation levels are all above 
90% breathing room air.  By the enrollee's own statement, the enrollee has a stationary concentrator and some 
kind of portable tank system that is too heavy for him. There is no documentation that oxygen saturation can be 
maintained >91% during activity using an oxygen conserving device. A portal oxygen concentrator is not 
medically necessary because Medicare criteria are not 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 the portable oxygen concentrator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the portable oxygen concentrator (E1392).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Visco-3. 
 
You asked the Plan to pre-approve Visco-3. You say that this drug is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says step therapy criteria have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Visco-3. Our reviewer says that this 
drug is not medically reasonable and necessary for the enrollee's condition. Our physician reviewer found that 
the Plan requires a trial of drugs Orthovisc or Supartz FX before they will approve the requested drug, Visco-3. 
There is no indication that the enrollee has tried and failed the required drugs. Based on the medical records 
provided and the Medicare-approved major drug compendia there is no indication that the plan's required drugs 
would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Visco-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Visco-3.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 10, 2022. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on January 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cystourethroscopy provided on March 7, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for a cystourethroscopy. You say that the member did not give the correct 
information. The Plan denied your request. The Plan says the enrollee must receive care from a network 
provider. 
 
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 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 a cystourethroscopy provided on March 7, 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 6 months rental enteral formula, nutritionally complete, 
for special metabolic needs, administered through an enteral feeding tube, 100 calories = 1 unit (B4154) IV 
pole (E0776) enteral infusion pump (B9002) feeding supply kit (B4035). 
 
You asked the Plan to pre-approve feeding pump, intravenous (IV) pole and 6 months supply of feeding supply 
kits and Diabetisource AC. You say that the records provided do not show that the enrollee has a condition that 
requires these supplies. The Plan denied your request. The Plan says the records provided do not show that the 
enrollee has a condition that requires these supplies. 
 
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 feeding pump, intravenous (IV) pole 
and 6 months supply of feeding supply kits and Diabetisource AC. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the available records support that the enrollee is not underweight and in fact maintains a baseline body 
mass index in the 19-20 range. The available records do not support ongoing intolerance to oral medications 
and nutrition, uncontrolled weight loss, obstructive enteropathy, nor irreversible GI tract dysfunction. The 
medical necessity for all items under review is not demonstrated by enrollee's provided records nor enrollees 
statement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of feeding pump, intravenous (IV) pole and 6 months supply of feeding supply kits 
and Diabetisource AC have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 
months rental enteral formula, nutritionally complete, for special metabolic needs, administered through an 
enteral feeding tube, 100 calories = 1 unit (B4154) IV pole (E0776) enteral infusion pump (B9002) feeding 
supply kit (B4035).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that you are appealing this denial. The Plan denied your 
request. The Plan says a ventilator is not covered by Medicare for the requested purpose, and the enrollee's 
needs could be met by a bi-level positive airway pressure (BiPAP) device with volume assured pressure 
support (VAPS) mode. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure therapy, regardless of the underlying medical condition, are not covered.  
 
We looked at the file and Medicare rules. A ventilator is not covered by Medicare for the requested purpose. 
Based on this information, we decided that Medicare rules for coverage of ventilator have not been met. 
Therefore, we decided that the Plan does not have to pre-approve use of a ventilator.
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 the enrollee has chronic hypercarbic 
respiratory failure from chronic obstructive pulmonary disease (COPD) and was recently admitted with 
dyspnea.The record indicates that the enrollee was successfully treated with standard bi-level positive airway 
pressure (BiPAP). 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 services are therefore 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse progressive lenses (V2781, S9999) provided on April 15, 
2022. 
 
  You asked the Plan to reimburse progressive lenses (V2781, S9999). You say that you feel this should be 
covered by insurance. You also say you have a benefit of up to $200 allowance. The Plan denied your request. 
The Plan says you have a $200 allowance for routine eyewear, and you received non-routine eyewear services. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to a $200 allowance per calendar year towards the purchase of routine eyeglasses 
or contact lenses. 
 
We looked at the file and the Plan's rules. The Plan rules say the Plan covers up to a $200 per calendar year 
towards the purchase of routine eyeglasses. The record shows that you received non-routine eyewear. Based on 
this information, we decided that the Plan's rules for coverage of progressive lenses (V2781, S9999) have not 
been met. Therefore, we decided that the Plan does not have to reimburse progressive lenses (V2781, S9999) 
provided on April 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an endoscopy provided on June 14, 2022. 
 
You asked the Plan to waive the copayment for an endoscopy. You say that you should not be responsible to 
pay this. 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 $75 
copayment for an endoscopy.  
 
 
 
 
 
 
 
 
 You have been asked to pay $75 for an endoscopy. This item/service falls within the endoscopy 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 endoscopy provided on June 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intra-abdominal omental flap provided to the enrollee on 
June 28, 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 procedure code 49905-GC is not supported by the medical records submitted. 
 
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 49905 is "Omental flap, intra-abdominal (List separately 
in addition to code for primary procedure)." 
 
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 operative report does not include 
sufficient documentation to confirm an intra-abdominal flap was performed. With CPT 49905, the provider 
repositions a flap of omentum, a fatty membrane in the abdominal cavity, to fill a defect during an abdominal 
surgery. He rotates the flap into place, without disrupting its vascular supply which require the following criteria: 1) description of the dissection of the omentum from the stomach and the transverse colon; 2) 
description of the division and ligation of vessels and mobilization and creation of the right or left 
gastroepiploic vascular pedicle; 3) description of the Suture Fixation of the flap to the adjacent or recipient 
tissue/organ. Operative report documents "The omentum was then mobilized and wrapped around the 
anastomosis. The bowel was placed back in its natural anatomical position." In this case, this procedure cannot 
be verified. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for an intra-abdominal omental flap provided to the enrollee on June 28, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory testing provided on October 14, 2021. 
 
You asked the Plan to pay for the testing services. You say that the testing identifies possible treatment options. 
The Plan denied your request. The Plan says that the testing is not a Medicare benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
In this case, the testing was provided to a patient with a solid tumor. The FDA approval notice indicates that 
the panel is approved for solid tumors. The Plan has not provided rationale indicating that the specimen does 
not meet one of the exceptions for the billed date of service. The Plan has not made reasonable and diligent 
efforts to gather and forward to us information regarding their decision to deny your request.  Therefore, we 
decided that the Plan has to pay for the laboratory testing provided on October 14, 2021.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care 
provided on March 01, 2021, to March 27, 2021. 
 
You asked the Plan to waive the copayment for the skilled nursing facility (SNF) care. You say that you were 
informed that you would not have to pay anything out of pocket. 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 $2,392 
copayment for skilled nursing facility (SNF) care. 
 
You have been asked to pay a $2,392 copayment for the skilled nursing facility (SNF) care. This item/service 
falls within the skilled nursing facility (SNF) 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. Per the EOC, there is a $184 copayment per day for days 21-100 
of skilled nursing care. Your stay lasted 33 days from February 22, 2021, to March 27, 2021. Your total for 
days 21-33 (13 days) is $2,392. Therefore, we decided that the Plan does not have to waive the copayment for 
the skilled nursing facility (SNF) care provided on March 01, 2021, to March 27, 2021.
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. The Plan denied your request. The Plan says based on the clinical 
information reviewed, this does not meet Medicare guidelines because the enrollee does not have skilled needs 
which can only be delivered in an inpatient basis in a skilled nursing facility. 
 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 is walking household distances with a rolling walker with contact guard 
assistance and is contact guard assist for transfers. Provided records do not document a significant decline in 
the enrollee's functional status to necessitate daily inpatient skilled therapy services. 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. Our reviewer also found 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.