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

 
We decided that the Plan does not have to pre-approve Nifedipine. 
 
You asked the Plan to pre-approve Nifedipine. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Nifedipine.  
 
Benefits for Nifedipine 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient rehabilitation provided from July 
10, 2022, to July 18, 2022. 
 
You asked the Plan to waive the copayment for inpatient rehabilitation. You say that you should have been 
transferred to avoid the copayments. You also say you were not given a choice and were unaware of the 
situation. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment per day for days 1 to 5. The Plan contract also says there is no charge for the remainder of your 
covered hospital stay and no limit to the number of days covered by the Plan based on medical necessity. for 
inpatient hospital care.  
 
 
  You have been asked to pay $1625 for inpatient rehabilitation ($325/day x 5 days = $1625). This item/service 
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 rehabilitation provided from July 10, 2022, to July 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that you are appealing this denial. The Plan denied your 
request. The Plan says a ventilator is not covered by Medicare for this purpose and the enrollee's needs could 
be met by a bilevel positive airway pressure (BiPAP) device instead. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide continuous or 
bilevel positive airway pressure therapy, regardless of the underlying medical condition, are not covered.  
 
We looked at the file and Medicare rules. A ventilator is not covered by Medicare for this purpose. Based on 
this information, we decided that Medicare rules for coverage of ventilator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve use of a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve Vertiflex. You say that the enrollee is in severe pain. The Plan denied your 
request. The Plan says Vertiflex is experimental/investigational. 
 
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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 
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 diabetic retinopathy 
with diabetic macular edema. She has not tried and failed the Plan's required drug, bevacizumab. The records 
do not show that the required drug would be contraindicated or less effective; therefore, Vabysmo 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 Vabysmo.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit coded 99211 provided on June 23, 2022. 
 
You asked the Plan to pay for the office visit. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services are not payable as billed. 
 
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 99211 is office or other outpatient visit for the evaluation 
and management of an established patient that may not require the presence of a physician or other qualified 
health care professional. 
 
We find that CPT code 99211 is not supported in the medical record. Specifically, this code was billed with a 
place of service 20 (urgent care facility). This code does for an established patient does not qualify for the place 
of service 20 coding. The claim is not payable as billed. Based on this information, we decided that Medicare 
rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to 
pay for the office visit coded 99211 provided on June 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive cardiovascular hereditary panel and a 
comprehensive pharmacogenomic (PGx) panel provided on May 2, 2022. 
 
You asked the Plan to pay for laboratory tests. You say that these tests were medically necessary and were 
ordered by the enrollee's physician. The Plan denied your request. The Plan says the criteria for medical 
necessity for these tests are not met. 
 
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 laboratory tests. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case, there is no documentation from the provider to indicate the drugs being considered 
for use, and there is no indication as to how the results of these tests will impact the enrollee's treatment. This 
review has determined that the criteria for coverage of these tests have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of laboratory tests have not been met. Therefore, we decided that the Plan does not 
have to pay for the comprehensive cardiovascular hereditary panel and a comprehensive pharmacogenomic 
(PGx) panel provided on May 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) and accessories 
rendered on November 18, 2021, to December 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating 
physician before dispensing any durable medical equipment (DME) item to a beneficiary. 
 
We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 pay for the pneumatic compression device (PCD) and accessories 
rendered on November 18, 2021, to December 8, 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 documentation shows that the enrollee has active comorbidities, however there are no 
complex functional deficits documented thus the complexity of the enrollee's nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation 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.
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 records provided support the need for 
LTACH care. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute 
care and is currently unstable for transfer to an LTACH. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where he is currently receiving care. All medically necessary care is being provided in the current 
acute care setting. There are no services available at the LTACH that the enrollee requires that are not available 
at the health care setting being offered by the health plan. The health plan has approved ongoing care in the 
current acute care setting. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 11, 2021 to 
February 17, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with the denial. The Plan denied your request. The Plan says the submitted records do not support the 
billing of DRG 270. 
 
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 DRG 270. 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 hospital services at the DRG originally billed. Our reviewer says 
that the submitted records do not support the billing of DRG 270. Our physician reviewer found the enrollee 
was admitted with complaints of bright red blood per rectum (BRBPR) that began a day prior. She tolerated a 
C-scope and upper endoscopy. A colonoscopy showed no evidence of a colonic source of bleeding or external 
hemorrhoids. The enrollee was hemodynamically stable. The records do not support the billing of DRG 270 
(Other Major Cardiovascular Procedures with major complications and comorbidity).  
 
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 provided on February 11, 2021 to February 17, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 93042 billed for date of service April 4, 2022. 
 
You asked the Plan to pay for code 93042. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says code 93042 is not separately payable from code 99291. 
Codes 99291 and 93010 billed on this date of service have already been paid. 
 
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 93042 
is a column II code to column I code 99291 with a modifier indicator of 0. The column II code is therefore 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 code 93042 billed for date of service April 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that your life is in jeopardy by denying this device. The 
Plan denied your request. The Plan says a ventilator is not covered by Medicare for this purpose and your needs 
could be met by a bilevel positive airway pressure (BiPAP) device instead. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure therapy  regardless of the underlying medical condition  are not covered.  
 
We looked at the file and Medicare rules. A ventilator is not covered by Medicare for the requested purpose. 
Based on this information, we decided that Medicare rules for coverage of ventilator have not been met. 
Therefore, we decided that the Plan does not have to pre-approve use of a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection of sclerosant; multiple incompetent veins, 
same leg (36471). 
 
You asked the Plan to pre-approve the injection. You say that the enrollee advised she has this done every year. 
You say that the enrollee is on her feet all day long for work. You also say that this has never been denied 
before. The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that invasive procedures for the treatment of varicose 
veins are considered medically reasonable and necessary when all the criteria have been met 
 
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 injection. Our reviewer says that the 
requested injection is not medically necessary. Our physician reviewer found the provided documentation does 
not indicate there has been a duplex report provided demonstrating absence of deep venous system obstruction 
or the elimination of truncal reflux. The reviewer found that the enrollees leg symptoms cannot be attributed to 
their varicose veins without assessment of lower extremity arterial perfusion, which has not been provided. The 
reviewer found that it is not clear that if the enrollee has recently been regularly using 20-30 mmHg 
compression stockings in a concerted effort to treat conservatively. Therefore, the reviewer found that the 
requested service is not 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve injection of sclerosant; multiple incompetent veins, same leg (36471).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SelectMDx genetic testing billed for date of service May 16, 
2022. 
 
You asked the Plan to pay for SelectMDx genetic testing. 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. 
 
The Plan must follow Medicare rules. The rules say that NGS as a diagnostic laboratory test is reasonable and 
necessary and covered nationally when the criteria listed in the Medicare rules section of this letter have been 
met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SelectMDx genetic testing have not been met. Specifically, we determined that SelectMDx genetic 
testing does not have FDA clearance. Therefore, we decided that the Plan does not have to pay for SelectMDx 
genetic testing billed for date of service May 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the back brace (L0650), provided on May 11, 2022. 
 You asked the Plan to pay for the back brace. You say that the item is medically necessary. The Plan denied 
your request. The Plan says this item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that if a spinal orthosis is provided and the coverage 
criteria are not met, the item will be denied as not 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 pay for the back brace. Our reviewer says that this 
item is not medically necessary. Our physician reviewer found the provided records do not include an 
examination of the back; the note does not document a recommendation for a back brace to reduce pain by 
restricting mobility of the trunk; or to facilitate healing following an injury to the spine or related soft tissues; 
or to facilitate healing following a surgical procedure on the spine or related soft tissue; or to otherwise support 
weak spinal muscles and/or a deformed spine. 
 
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 back brace have not been met. Therefore, we decided that the Plan does not 
have to pay for the back brace (L0650), provided on May 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 93042 provided on January 8, 2022. 
 
You asked the Plan to pay for code 93042. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says payment for the services billed are bundled into another code. 
 
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 93042 
is a column II code to column I code 99291 with a modifier indicator of 0. The column II code is therefore 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 code 93042 provided on January 8, 2022.