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

We decided that the Plan does not have to pre-approve ophthalmology care to be provided by an OON
provider.
You asked the Plan to pre-approve ophthalmology care. You say that this provider has new procedures and
technologies that are not yet available at other providers. The Plan denied your request. The Plan says the
denial of authorization for this service is correct, because this provider is out-of-network with the Plan, and you
can be treated by an in-network ophthalmologist.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must 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
ophthalmology care to be provided by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prochlorperazine 10mg tablet.
You asked the Plan to pre-approve prochlorperazine. You say that the enrollee is experiencing breakthrough
nausea and vomiting despite intravenous antiemetics given prior to receiving chemotherapy and oral
Ondansetron at home. The Plan denied your request. The Plan says the requested drug does not meet the
criteria for coverage under Medicare Part B. The Plan says that the requested drug is considered selfadministered.
The Plan also says self-administered drugs are covered under a Medicare Part D prescription
drug plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 prochlorperazine 10mg
tablet.
Benefits for prochlorperazine 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Morphine sulfate for the enrollee.
You asked the Plan to pre-approve this drug. You say that the enrollee needs this for chronic pain. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Morphine sulfate for the enrollee.
Benefits for this drug 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90837) provided on May 14 to May 25, 2021, by an out-of-network provider.
You asked the Plan to pay for psychotherapy services. You say that you were given incorrect coverage information by the enrollee. The Plan denied your request. The Plan says rules for out-of-network care have not been met.
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 items/services 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 psychotherapy services (90837) provided on May 14 to May 25, 2021, by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
You asked the Plan to pre-approve additional routine transportation trips. You say that you want the Plan to approve additional trips. The Plan denied your request. The Plan says you have utilized the maximum number of transportation trips allowed per year.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 48 trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a practitioner visit provided on February 2, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for practitioner visit. You say that due to the setting of service, it is not always 
possible to obtain authorization. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because this provider is out-of-network with the Plan and authorization was not obtained. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 practitioner visit provided on February 2, 2021 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81479) provided on October 12, 2020.
You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan denied your request. The Plan says there is not an order for this service.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (81479) provided on October 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided July 7, 2020 to July 14, 2020 
billed with DRG 871. 
 
You asked the Plan to pay for the inpatient services billed with DRG 871. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
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 secondary diagnosis R65.21, defined as Severe 
sepsis with septic shock. 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 inpatient 
services billed with DRG 871. Our reviewer says that the documentation does not support the DRG billed. Our 
physician reviewer found the enrollee presented with reported CVA to the hospital with a lactic acid of 2.7 
improved to 1.0 after fluids, elevated procalcitonin of 1.52, and hypovolemia. Procalcitonin was not repeated 
after fluids. The documentation does not support a secondary diagnosis of R65.21 Severe sepsis with septic 
shock on admission as lactic acid was improved with fluids and there was no repeat procalcitonin to show 
persistent severe septic shock on admission. There was insufficient support in the clinical documentation for 
this diagnosis on admission. Therefore, the DRG billed is not supported by the documentation.  
 
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 the inpatient services provided July 7, 2020 to July 14, 2020 billed with DRG 871.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (63047, 63048) provided on April 20, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
payable. 
 
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, we have confirmed that code 63047 
is a column II code to column I code 22633. Based on the claim submitted, Medicare billing criteria have not 
been met. Additionally, we have confirmed that code 63048 is an add-on code. As the primary procedure code, 
63047, is not payable in this case, the add-on code is also not payable. Based on the claim submitted, Medicare 
billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services 
(63047, 63048) provided on April 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Corus coronary artery disease (CAD) testing provided on 
August 31, 2020. 
 
You asked the Plan to pay for the Corus coronary artery disease (CAD) testing. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that the Corus CAD test is non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Corus coronary artery disease (CAD) testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the Corus coronary artery disease (CAD) testing provided on August 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.
You asked the Plan to pre-approve these services. You say that you want a smaller scooter because your current one doesn't fit in your bathroom. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have a three-wheeled small scooter. Your current scooter serves the same purpose as the requested scooter. The file shows that the current scooter is not damaged or more than five years old. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility.
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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for blood bank physician services (86078) provided February 2, 
2021.  
We decided that the Plan does not have to pay for blood bank physician services (86078) provided February 2, 
2021. 
You asked the Plan to pay for the physician services. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the submitted documentation 
supports 1 unit of 86078, which has been approved. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. Medicare rules say that claims submitted where the unit of service exceeds 
the MUE value cannot be paid when the MAI value is 3. 
 
We find that the total units of service billed exceeds the allowed unites of 1. You billed for 2 units of this code, 
exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the physician 
services have not been met. Therefore, we decided that the Plan does not have to pay for blood bank physician 
services (86078) provided February 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2310,
K0108) for the enrollee.
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied
your request. The Plan says the enrollee has adequate upper limb strength and function to be able to control the
power option using its own switch which is included in the allowance of the power options.
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 accessories. 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 needs to control up to twp power seating
options through a joystick. The documentation does not support the need for a small calf pad.
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 accessories have not been met. Therefore, we decided that the Plan does not
have to pre-approve additional power wheelchair accessories (E2310, K0108) for the enrollee.
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 the medical management criteria
and need for physician oversight. You say that the enrollee will not make the significant gains necessary to
return home safely if his care is provided at a lower level. The Plan denied your request. The Plan says the
guidelines for coverage of IRF care have not been met. The Plan says that the enrollee could receive the care
needed in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for surgical repair of a femur fracture after a fall. The enrollee's medical problems are stable.
There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy
program. While the documentation does support a need for physical and/or occupational therapy, there is no
documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable
expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation
therapy program provided in an IRF.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve F2 gene (prothrombin coagulation factor II) and F5
gene (coagulation factor V) testing.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your
request. The Plan says medical necessity has not been established.
The Plan must follow Medicare rules. Medicare rules say that F2 gene (prothrombin coagulation factor II) and
F5 gene (coagulation factor V) The F2 and F5 genetic tests are not considered to be clinically efficacious.
Medicare does not consider this testing to be medically reasonable or necessary. Based on this information, we
decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan
does not have to pre-approve F2 gene (prothrombin coagulation factor II) and F5 gene (coagulation factor V)
testing.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and
services.
You asked the Plan to pay for IRF care. You say that you need to be transferred to an IRF. The Plan denied
your request. The Plan says the criteria for admission to an IRF are not met. The necessary services can be
provided in 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 pay for 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 that the complexity of your nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the
documentation does support a need for physical and/or occupational therapy, there is no documented need for
an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
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 pay for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on February 2, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that coverage for all CV risk assessment panels, except the basic lipid panel, is denied for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. We looked at the file and Medicare rules. Per LCD L36358, the requested cardiovascular risk assessment panel is not a covered service. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on February 2, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional dental extractions. 
 
You asked the Plan to pre-approve the extractions. You say that the enrollee cannot eat or receive dentures until 
the teeth are extracted. The Plan denied your request. The Plan says the benefit has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file, and Medicare rules. The file shows that 11 dental extractions were requested. The Plan 
approved 3 extractions. Your plan only covers 3 extraction procedures per calendar year. We found no 
exception which would require the Plan to approve additional extractions. Therefore, we decided that the Plan 
does not have to pre-approve additional dental extractions.