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

 
We decided that the Plan does not have to pre-approve treatment with Stelara injection. 
 
You asked the Plan to pre-approve Stelara. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Stelara 
injection.  
 Benefits for Stelara 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from April 2, 2020, to May 3, 2020. 
 
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 the provider has reported skilled services with the incorrect PDPM Health Insurance Prospective 
Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We 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. The provider billed a PDPM score of JBEC1. 
The 4th alphanumeric character - "C" - requires a non-therapy ancillary score of 6-8, with evidence of IV 
medication and a diagnosis of cirrhosis of the liver. Our reviewer says that the services at issue in this case 
were not supported by the medical records. Our reviewer found that for the period of April 2, 2020, to May 3, 
2020 , the documentation does not support that there was a then active diagnosis of cirrhosis of the liver that 
would have a direct relationship to the enrollee's functional status, cognitive status, mood or behavior status, 
medical treatments, nursing monitoring, or risk of death. 
 
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 skilled nursing facility (SNF) services provided to the enrollee from April 2, 2020, to May 3, 
2020.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Opdivo and Abraxane to be used with Carboplatin. 
 
You asked the Plan to pre-approve the requested drugs. The Plan denied your request. The Plan says that 
Abraxane and Carboplatin should be taken with Keytruda. 
 
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 requested drugs. Our physician 
reviewer found that the enrollee has stage II non-small cell squamous lung cancer. Although Keytruda is 
recommended for stage IV disease, the FDA has approved a cddp doublet with Opdivo. Neoadjuvant treatment, 
in combination with platinum-double chemotherapy is supported for resectable (tumors greater than or equal to 
4 centimeters or node positive) non-small cell lung cancer in adults. The documentation does support that the 
requested drug regimen is safe and effective and otherwise reasonable and necessary for this 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 the requested drugs have been met. Therefore, we decided that the Plan has to 
pre-approve Opdivo and Abraxane to be used with Carboplatin.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tissue exam (88305) provided on September 21, 2021. 
 
You asked the Plan to pay for the tissue exam. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the member was an outpatient on this date of 
service and that the facility rendered procedure 88305 on the date of service September 21, 2021. 
 
The Plan must follow Medicare rules. Medicare rules say that an independent laboratory may not bill the 
Medicare contractor for the TC of a physician pathology service furnished to a hospital inpatient or outpatient. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the tissue exam have not been met. Specifically, the record indicates that the enrollee was an 
outpatient on the billed date of service. The record also shows that the facility billed this service on the same 
date of service. It is not appropriate for an independent laboratory to bill for the TC of a physician pathology 
service when the enrollee is a hospital outpatient. Therefore, we decided that the Plan does not have to pay for 
the tissue exam (88305) provided on September 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that this device is medically 
necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
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 specifically being requested 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 portable oxygen concentrator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided on July 22, 2020. 
 
You asked the Plan to pay for home health care. You say that these services were coded correctly and 
submitted timely. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because this claim was not billed with the appropriate Q- code. 
 The Plan must follow Medicare rules. Medicare rules say that home health agencies must report one of three Q- 
codes (Q5001, Q5002, or Q5009) reflecting the location of service along with the first visit reported on a claim.  
 
We looked at the file and Medicare rules. This claim does not include the required location of service Q- code. 
Based on this information, we decided that Medicare rules for coverage of home health care have not been met. 
Therefore, we decided that the Plan does not have to pay for home health care provided on July 22, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study (95810). 
 
You asked the Plan to pre-approve a sleep study. You say that you have difficulty breathing when laying down. 
You also say that you need this service. The Plan denied your request. The Plan says the sleep study is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a sleep study. Our reviewer says that 
the requested sleep study is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the criteria for a sleep study were not met, namely signs or symptoms suggestive of obstructive 
sleep apnea (OSA). The reviewer found that there was no contraindication to using a home sleep study. 
Therefore, this request for sleep study in lab will be considered not medically necessary at this time. 
 
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 sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study (95810).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair, group 2 standard, captains chair, 
patient weight capacity up to and including 300 pounds (K0823) 
 
You asked the Plan to pre-approve a power wheelchair. You say that your shoulders hurt, and you are unable to 
push yourself with the manual wheelchair. You also say you have fallen out several times and you need the 
power chair. The Plan denied your request. The Plan says you do not meet the Medicare guidelines for a power 
mobility device. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that you do not have a mobility deficit that impairs your participation in MRADLs. This means 
that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power wheelchair, group 2 standard, captains chair, patient weight capacity up to and 
including 300 pounds (K0823)
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on September 6, 
2021. 
 
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 Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. 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 laboratory services provided to the enrollee on September 6, 2021.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve 9 additional home health physical therapy visits. 
 
You asked the Plan to pre-approve 9 additional home health physical therapy visits. You say that the 9 
additional home health physical therapy visits are medically necessary. The Plan denied your request. The Plan 
says that the 9 additional home health physical therapy visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 9 additional home health physical 
therapy visits. Our reviewer says that the 9 additional home health physical therapy visits are medically 
necessary. Our physician reviewer found clinical documentation is very detailed in the goals of continued home 
health physical therapy by both provider and physical therapist. The enrollee has multiple medical conditions 
and is documented as not yet stable with home exercise regimen thus continued therapy would require the skill 
of a professional therapist. The enrollee is still using an assistive device and gait instability due to osteoarthritis 
which is an appropriate or well excepted diagnosis for requiring physical therapy as part of a treatment plan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 9 additional home health physical therapy visits have been met. Therefore, we 
decided that the Plan has to pre-approve 9 additional home health physical therapy visits.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The enrollee is medically stable with no new and acute medical problems and does not need physical medicine and 
rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical conditions. There are no acute rehab nursing needs identified 
or documented in the record. At the current functional level, the enrollee does not need intensive therapies, 
consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach in an 
IRF. IRF admission is not medically necessary based on medical stability and lack of medical complexity, and 
lack of rehab nursing needs in addition to high functional level. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on October 18, 
2021. 
 
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 15734 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 15734 is "Muscle, myocutaneous, or fasciocutaneous 
flap; trunk." 
 
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 csae Our reviewer found the eview has determined that the records did not support that CPT 15734 was 
rendered in this case. The records did not support the coding of CPT 15734. In this case incisions made to 
separate the posterior rectus sheath from the rectus muscle in order to place mesh in the retrorectus space 
without a transversus abdominis release constitutes a Rives-Stoppa repair, which is not to be coded as 15734. CPT code 15734 may be reported only when myofascial flaps are created by myofascial releases. 
 
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 surgical services provided to the enrollee on October 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vascepa. 
 
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 self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Vascepa.  
 
 
 
 Benefits for these services 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 pay for the progressive lenses (V2781) and the deluxe frames 
(V2025) rendered by the out-of-network (OON) provider on January 26, 2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says the items were rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items at issue in this appeal. The Plan did not pre-approve the items at issue.  We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan 
does not have to pay for the progressive lenses (V2781) and the deluxe frames (V2025) rendered by the out-of-
network (OON) provider on January 26, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve services performed by a qualified physical therapist in the home 
health or hospice setting, each 15 minutes (G0151 x 7). 
 
You asked the Plan to pre-approve home health services. You say that the enrollee does not have any family to 
help them. You also say that the services are medically necessary. The Plan denied your request. The Plan says 
that the requested home health services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the home health services are medically necessary. Our physician reviewer found the provided 
documentation states that the enrollee has made improvement but still requires maximum assist with bed 
mobility and transfers with assistive device. The reviewer found that the enrollee is documented at not being at 
a stable level of function for home exercise plan or custodial care. Therefore, the reviewer found that the 
enrollee would continue to require the skill of a professional therapist for continued improvement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have been met. Therefore, we decided that the Plan has to 
pre-approve services performed by a qualified physical therapist in the home health or hospice setting, each 15 
minutes (G0151 x 7).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on March 25, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that 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 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 drug testing services provided on March 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $40 copayment for an office visit on January 25, 2022. 
 
You asked the Plan to waive the $40 copayment for an office visit with a specialist. You say that you have 
never paid a copayment for a visit with this specialist.  The Plan denied your request. The Plan says the 
assessed $40 copayment is correct. 
 
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 $40 for 
each in-network specialist visit.  
 
 
 
 
 
 
 
 You have been asked to pay a $40 copayment for an office visit with a specialist. Office visits with a specialist 
fall within the outpatient hospital 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 $40 
copayment for an office visit on January 25, 2022.