Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture treatment provided from October 29, 2021, 
through December 10, 2021. 
 
You asked the Plan to pay for acupuncture treatment. The Plan denied your request. The Plan says this provider 
is not supervised by any physician, PA, or NP/CNS. 
 
The Plan must follow Medicare rules. The rules say that these treatments may be provided by a physician in 
accordance with state requirements, or by physician assistants, nurse practitioners/clinical nurse specialists, and 
auxiliary personnel if they meet certain licensure requirements. Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, physician assistant, or nurse 
practitioner/clinical nurse specialist.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, there is no documentation that the acupuncture 
treatment at issue in this appeal meets the Medicare coverage criteria. The provided records do not document 
that the acupuncturist in this case was under the appropriate level of supervision of a physician, PA, or 
NP/CNS. Therefore, we decided that the Plan does not have to pay for acupuncture treatment provided from 
October 29, 2021, through December 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 
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 step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has iron deficiency anemia 
with intolerance or unsatisfactory response to an oral iron replacement. She has not tried and failed the Plan's 
required drugs, Infed and Venofer. The records do not show that the required drugs would be contraindicated or 
less effective; therefore, Feraheme is 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 Feraheme.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on December 23, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that the provider relied on the assisted living 
facility's staff to verify eligibility. The Plan denied your request. The Plan says unauthorized, non-plan care is 
not covered. 
 
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 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 medical services provided on December 23, 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 rendered on October 8, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on October 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDX melanoma test provided to the enrollee on 
January 3, 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 the service required an authorization. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not support that the enrollee's diagnosis was diagnostically uncertain or 
controversial by histopathology. The documentation does not support that there is a recognized decision impact 
of these biomarkers by the clinical community. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the DecisionDX melanoma test provided to the enrollee on January 3, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after June 
12, 2022. 
 
You asked the Plan to pre-approve continued SNF care. You say that you are not yet finished with rehab and it 
is mandatory that you do so. The Plan denied your request. The Plan says continued SNF care after June 12, 
2022, is not medically necessary. 
 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 continued SNF care. Our reviewer says 
that continued SNF care is not medically necessary. Our physician reviewer found from a nursing perspective, 
you received oral medications and were monitored for orthostasis. Your were clear and you were treated for 
pain. Regarding rehabilitation services, you received physical and occupational therapy.  You were at a stand 
by assist to minimal assist level for functional mobility including gait to short distances.  You were 
independent with your activities of daily living. You have no identifiable skilled nursing service needs or 
skilled therapy service needs 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care after June 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus vaccine received on January 4, 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 this was not billed with an appropriate diagnosis. 
 In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The 
Plan follows the same rules. Medicare rules say also say that providers must report services correctly. 
 
Records do not show that you have been injured or directly exposed to any illness related to the services. 
Additionally, it is not appropriate in this case to bill a column II code like CPT 82947 with its column I code 
(80053). There was no appropriate modifier billed to bypass this coding edit. Therefore, we decided that the 
Plan does not have to pay for the tetanus vaccine received on January 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eye care services provided on November 6, 2020. 
 
You asked the Plan to pay for eye care services. You say that the services at issue were a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the 
claim at issue was filed untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for eye care services was not filed until January 14, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for eye care services provided on November 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit. 
 
You asked the Plan to pre-approve Procrit. You say that the requested Procrit is medically necessary. The Plan 
denied your request. The Plan says the requested Procrit is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Procrit. Our reviewer says that the 
requested Procrit is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has a diagnosis of chronic kidney disease stage IV. The record does not indicate that the enrollee may 
require a transfusion without the requested treatment. The Food and Drug Administration has not stated that the 
requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not contain 
a supportive citation for the use of the requested drug in the enrollee's clinical situation. 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 Procrit have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Procrit.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for additional x-ray services provided to the enrollee on January 10, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the records submitted do not indicate that two separate services were performed/supported 
by this provider. 
 
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 71045 is "Radiologic examination, chest; single view." 
 
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 enrollee had two separate single 
view chest x-rays - CPT 71045 - on January 10, 2022. The first was signed by one doctor at 6:06am, while the 
second one was signed by a different doctor at 15:01pm. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
additional x-ray services provided to the enrollee on January 10, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital admission from October 
16, 2021 to October 27, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital admission. You say that you believe you 
should only be charged one copayment. The Plan denied your request. The Plan says you have been charged 
the correct copayment amount. 
 
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 $350 
copayment per day, days 1-5 and $0 for additional days at an in-network hospital.  
 
You have been asked to pay $3,500 ($350/per day x 5 = $1,750) ($1,750/stay x 2 inpatient stays = $,3500). 
Inpatient hospital admission falls within the Inpatient hospital 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 inpatient hospital admission from October 16, 2021 to October 27, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services at a higher Diagnosis Related 
Group (DRG). 
 You asked the Plan to pay for inpatient hospital services at a higher DRG. You say that the DRG should be 
paid as billed. The Plan denied your request. The Plan says the DRG was downgraded because the secondary 
diagnosis of J96.01 (acute respiratory failure with hypoxia) is not supported in the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with a secondary diagnosis of J96.01 (acute respiratory 
failure with hypoxia). 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 inpatient hospital services 
at a higher DRG. Our reviewer says that a secondary diagnosis of J96.01 (acute respiratory failure with 
hypoxia) is not supported is the medical record. Our physician reviewer found the documentation throughout 
this hospital stay does not support acute respiratory failure. The enrollee was admitted on July 24, 2021 for 
atrioventricular block. Although the documentation supports a oxygen saturation less than 90% on room air, 
and acute respiratory failure is documented, this diagnosis is not supported.  Symptoms and treatment of acute 
respiratory failure is not documented (shortness of breath, respiratory distress, confusion etc.), mechanical 
ventilation to validate diagnosis.  Of note, the discharge summary does not mention care and treatment of acute 
respiratory failure, as well as a "resolved problem".  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services at a higher Diagnosis Related Group (DRG).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Shingles vaccine you received on February 16, 2022. 
 
You asked the Plan to pay for the Shingles vaccine. You say that you were told this vaccine would only cost 
$47. The Plan denied your request. The Plan says this vaccine is not covered under your medical benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingles 
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 Shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for the Shingles vaccine you received on 
February 16, 2022.  
 
Benefits for the Shingles 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 17, 2021. 
 
You asked the Plan to pay for an office visit. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on November 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 15, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
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 these 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 rendered on June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Skilled Nursing Facility services provided on December 13, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Skilled Nursing Facility services. You say that the services provided were 
medically necessary. The Plan denied your request. The Plan says the provider is out-of-network and it was 
determined these services were 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 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 Skilled Nursing Facility services provided on 
December 13, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fully reclining wheelchair (E1050) provided on May 18, 
2021. 
 
You asked the Plan to pay for the fully reclining wheelchair. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this item was not 
purchased from a provider certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the fully reclining wheelchair (E1050) 
provided on May 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the next generation sequence testing provided on January 9, 
2022. 
 
You asked the Plan to pay for the next generation sequence testing. You say that you would like this claim 
reprocessed based on the medical records. The Plan denied your request. The Plan says this is not a Medicare 
benefit and is a statutorily excluded service. 
 
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 next generation sequence testing 
provided on January 9, 2022, have been met. In this case, the documentation provided does not include medical 
records indicating the enrollees history and the reason for why this testing was ordered.  Therefore, we decided 
that the Plan does not have to pay for the next generation sequence testing provided on January 9, 2022.