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

 
We decided that the Plan does not have to pay for the CxBladder testing (0013M) provided on August 12, 
2021. 
 
You asked the Plan to pay for the CxBladder testing. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this testing is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that after a review of the literature, non-coverage has 
been reaffirmed for the CxBladder test. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CxBladder testing have not been met. Specifically, the CxBladder is not a covered test at this 
time. Therefore, we decided that the Plan does not have to pay for the CxBladder testing (0013M) provided on 
August 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 19, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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 laboratory 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 laboratory services provided on October 19, 2021.
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 enrollee meets IRF criteria and that IRF care 
would preserve motor function and lower risk of complications and falls. The Plan denied your request. The 
Plan says IRF admission is not medically necessary, and the enrollee can be managed 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. Our 
physician reviewer found the enrollee is medically stable, with no new medical issues, and does not need 
physician close supervision 3 times per week (at a minimum) for the ongoing management of any active or 
acute exacerbations of chronic medical conditions. With a chronic disease, 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 to daily therapy in an IRF. While the enrollee may benefit from PT and OT, the enrollee's rehab needs 
can be safely provided at a lower intensity and alternate 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services (99308) provided on June 15, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 
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 the physician services (99308) provided on June 
15, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a sleep study for the enrollee. 
 
You asked the Plan to pre-approve the study. You say that this is medically necessary, as there is a significant 
cardiac history which puts the patient at risk for sleep-disordered breathing. The Plan denied your request. The 
Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered 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 the study. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found a home sleep study is reasonable and medically necessary for this enrollee. The enrollee has refractory 
insomnia, frequent awakening, and subjective daytime sleepiness, although the Epworth score is normal. A 
home sleep test is a reasonable screening test for obstructive sleep apnea (OSA). If OSA is found, an attended 
sleep study will not be 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 study have been met. Therefore, we decided that the Plan has to pre-approve 
a sleep study for the enrollee.  
 
 
 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 pre-approve a right shoulder arthroscopic surgery for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says the documentation submitted does not show any physical therapy, occupational therapy, 
or home exercises and activity modifications for at least six weeks. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has not undergone adequate conservative measures to include physical therapy. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a right shoulder arthroscopic surgery for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hymovis for the enrollee. 
 
You asked the Plan to pre-approve Hymovis. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no indication their preferred agents would likely be less effective, and/or 
cause adverse effects for the member. 
 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 Hymovis. Our reviewer says that 
Hymovis is not medically reasonable and necessary. The enrollee has osteoarthritis of the knee. The requested 
medication is a new start. The provided records do not indicate that the enrollee has tried and failed the Plan's 
preferred step one alternatives. The record does not indicate that the enrollee has a contraindication to or would 
have an adverse effect from the Plan's preferred step one alternative. Our physician reviewer found that the 
enrollee's condition does not meet step therapy criteria for Hymovis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hymovis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hymovis for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from September 2, 2021, to 
September 10, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient hospital care provided 
from September 2, 2021, to September 10, 2021, was medically necessary. The Plan denied your request. The 
Plan says that the inpatient hospital care provided from September 2, 2021, to September 10, 2021, was not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the inpatient hospital care provided from September 2, 2021, to September 10, 2021, was medically 
necessary. Our physician reviewer found the review indicates that the record showed that at the time of 
inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care 
(including earlier emergency department (ED) and/or observation care) would span two midnights. The 
inpatient hospital care was 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from September 2, 2021, to September 10, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection for a power wheelchair 
(E2311) for the enrollee. 
 
You asked the Plan to pre-approve the electronic connection. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee's upper limb strength and function are adequate for the enrollee 
to be able to control the power options/features using their own switches which are included in the allowance 
of these power options/features. 
 
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 electronic connection. Our reviewer 
says that the requested electronic connection is not considered medically reasonable and necessary in this case. 
Our physician reviewer found based on the medical records provided there is no documentation that supports 
the medical necessity of the requested electronic connection for a power wheelchair (E2311) as defined by 
Medicare criteria. The provided records document that the enrollee has 3/5 upper extremity strength and 
requires only set-up assistance for most activities of daily living such as grooming, bathing and dressing, thus 
indicating she has adequate upper extremity strength and function to operate the wheelchairs power options 
with their own switches. 
 
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 electronic connection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an electronic connection for a power wheelchair (E2311) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF admission. You say that you were independent at home prior to your 
hospitalization and feel that you could use additional therapy to get stronger to return home independently. You 
said that you feel as though you still needs some help at this time and you can't return home alone. The Plan 
denied your request. The Plan says you do not required SNF admission and you care needs can be met at a 
lower level.  
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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you have no skilled nursing needs at this 
time.  The doctor says that you do require skilled therapy services, but the documentation does not support that 
it is medically reasonable and necessary to provide skilled therapy services on a "daily basis" on an inpatient 
basis in a skilled nursing facility 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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laminotomy for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not demonstrate that the enrollee has adequately participated in 
conservative measures for the associated symptoms. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no documentation of adequate conservative measures to include physical therapy for back pain. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve laminotomy for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient therapy services provided on September 1, 
2021, to September 24, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient therapy services provided by an OON provider. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-
network care. 
 
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 the outpatient therapy services provided on 
September 1, 2021, to September 24, 2021, 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 services provided on August 10, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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 laboratory 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 laboratory services provided on August 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 single power option power wheelchair 
(K0856), a power tilt system (E1002), and accessories (E2361, E2620, E0955, E1028, E1012, E0953, E2622, 
E2311). 
 You asked the Plan to pre-approve a group 3 single power option power wheelchair, a power tilt system, and 
accessories. You say that these items are medically necessary. The Plan denied your request. The Plan says the 
enrollee does not meet the requirements for a power tilt system. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with Single 
Power Option (K0856) is covered if the beneficiary meets coverage criteria for a power tilt and recline seating 
system and the system is being used on the wheelchair, or the beneficiary uses a ventilator which is mounted on 
the wheelchair. A power tilt and recline seating system is covered if the beneficiary is at high risk for 
development of a pressure ulcer and is unable to perform a functional weight shift, the beneficiary utilizes 
intermittent catheterization for bladder management and is unable to independently transfer from the 
wheelchair to bed, or the power seating system is needed to manage increased tone or spasticity. 
 
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 group 3 single power option power 
wheelchair, a power tilt system, and accessories. Our reviewer says that the requirements for coverage of the 
requested items have not been met. Our physician reviewer found there is no documentation that the enrollee is 
high risk for development of a pressure ulcer and is unable to perform a functional weight shift. The records do 
not indicate he utilizes intermittent catheterization for bladder management and is unable to independently 
transfer from the wheelchair to bed. The power seating system is not needed to manage increased tone or 
spasticity. The records indicate that the enrollee is at moderate risk for skin breakdown, that he uses adult 
diapers rather than bladder catherization, and that his tone normal. 
 
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 group 3 single power option power wheelchair, a power tilt system, and 
accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 
single power option power wheelchair (K0856), a power tilt system (E1002), and accessories (E2361, E2620, 
E0955, E1028, E1012, E0953, E2622, E2311).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87496, 87498, 87631, 87798, 87486, 
87541, 87581, and 87640) provided on January 6, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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 laboratory 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 laboratory services (87496, 87498, 87631, 87798, 87486, 87541, 
87581, and 87640) provided on January 6, 2021.