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

 
We decided that the Plan does not have to pre-approve treatment with Gammagard (J1569). 
 
You asked the Plan to pre-approve Gammagard. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for the requested drug have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that IVIG may be used in patients with severe active 
illness for whom other interventions have been unsuccessful, have become intolerable or are contraindicated. 
 
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 Gammagard. Our reviewer says that the 
requested drug is not considered medically reasonable and necessary in this case. Our physician reviewer found 
that the enrollee has not had a trial of steroids or other immunosuppressive agents. It cannot therefore be said 
that the enrollee has refractory disease or that other interventions have been unsuccessful, have become 
intolerable, or are contraindicated. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gammagard have not been met. Therefore, we decided that the Plan does not 
have to pre-approve treatment with Gammagard (J1569).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve continuation of inpatient mental health care from May 11, 2022, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the services are 
necessary. The Plan denied your request. The Plan says that the services are not necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. 
Our physician reviewer found you do meet the criteria for treatment in an acute inpatient mental health 
treatment beyond the date in question of May 12, 2022, forward and could not have been treated in a lesser 
restrictive setting as although you were not showing any suicidal or homicidal ideation, auditory or visual 
hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant 
while not showing any acute threats to safety, you were having your medication titrated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pre-approve continuation of inpatient mental health care from May 11, 2022, forward.  
 
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 pay for Diabetic shoes provided on November 18, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Diabetic shoes. You say that you feel these sneakers should be covered as your 
old provider is no longer contracted for your diabetic shoes. The Plan denied your request. The Plan says the 
provider is out-of-network and authorization is required prior to an out-of-network provider. 
 
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 Diabetic shoes provided on November 18, 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 drug testing services provided on June 17, 2021. 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 
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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does 
not have to pay for the drug testing services provided on June 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 31, 2021. 
 
You asked the Plan to pay for the lab services. You say that the treatment sought was medically necessary. The 
Plan denied your request. The Plan says the billed services remain not supported. 
 
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. The file shows that a comprehensive cardiac panel was provided. We looked at the file and Medicare rules. The 
claim in this case was billed with the laboratory POS code. The records do not support that the sample was 
taken in a laboratory setting. Furthermore, it appears the testing may have been ordered by an unsolicited 
outreach telephone call to the enrollee. The records do not show that the testing was initiated by the enrollee or 
the enrollee's treating physician. Based on this information, we decided that Medicare rules for coverage of the 
lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services 
provided on March 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs to be admitted to an IRF as it is 
medically necessary. The Plan denied your request. The Plan says the enrollee's ongoing skilled therapy and 
nursing needs can be provided at a lower level of care such as at a Skilled Nursing Facility, on an intermittent 
basis at home with home health care, or in a long-term care 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 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 pay for Prostate cancer screening (G0103) provided July 12, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the prostate cancer screening, prostate 
specific antigen test (PSA) (G0103) provided July 12, 2021. The Plan denied your request. The Plan says this 
claim was processed with the correct cost share applied per the Evidence of Coverage. 
 
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan 
contract says that the Plan covers prostate cancer screening for men age 50 and older once every 12 months. 
 
You have been asked to pay $148.48 for the laboratory services. The records show that this service was already 
provided and covered by the Plan for date of service January 11, 2021. The Plan covers this service once every 
12 months. The laboratory services fall within the Prostate cancer screening exams 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 pay for Prostate cancer screening (G0103) provided July 
12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on 
November 9, 2021. 
 
You asked the Plan to pay for the special anesthesia service (99100). You say that the medical records should 
be reviewed, and the claim reprocessed for payment. The Plan denied your request. The Plan says CPT codes 
01214, 76942 and 64447 have been overturned. The Plan also says that CPT code 99100 remains denied as 
bundled services are not eligible for separate reimbursement.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the special anesthesia service (99100) have not been met. Therefore, we decided that the Plan does not have 
to pay for the special anesthesia service (99100) provided on November 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied 
your request. The Plan says an evaluation for respiratory therapy can be offered.] 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
To qualify for home oxygen, the patient must meet one of the following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep;  
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, 
there is a rebuttable presumption of non-coverage. 
 
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 concentrator. Our reviewer says that 
the requested concentrator is not medically reasonable or necessary. Our physician reviewer found a portable 
oxygen concentrator (POC) is considered not medically necessary because Medicare coverage criteria are not 
met. This patient has an oxygen requirement following COVID-19, and has a stationary oxygen concentrator 
and portable E-tanks. The patient states she is unable to leave the house because the tanks are too 
heavy. Medicare requires demonstration that SpO2 of at least 91% can be maintained during ambulation using 
an oxygen conserving device and no more than 4 L/min flow. This needs to be done before the POC can be 
approved. 
 
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 concentrator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a portable oxygen concentrator.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 
You asked the Plan to pre-approve Eylea. You say that this drug is medically necessary. The Plan denied your 
request. The Plan says step therapy criteria have not been 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 Eylea. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a 
trial of Avastin before they will approve the requested drug. In this case, the patient has not tried and failed the 
required drug(s). There is no documentation provided indicating that the Plans required drug(s) would likely 
be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(BVN), including all imaging guidance (64628). 
 
You asked the Plan to pre-approve the diagnostic service. You say that you have tried multiple conservative 
therapies that have not worked. The Plan denied your request. The Plan says the requested procedure is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the diagnostic service. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there have been no specific studies done to identify that the BVN is the cause of your 
pain. Therefore, the reviewer found that the requested procedure is not medically necessary or reasonable. 
 
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 diagnostic service have not been met. Therefore, we decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (BVN), including all 
imaging guidance (64628).
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance services (A0427, A0425) provided on September 13, 
2021. 
 
You asked the Plan to pay for the ambulance services. You say that these services were medically necessary 
and should be paid. The Plan denied your request. The Plan says that this claim was not billed with a valid 
diagnosis for the procedure provided. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the case file forwarded by the Plan does not include the original 
claim that was submitted for payment. Without the original claim, we cannot verify how these services were 
billed. In addition, there is no governing Medicare rule for the location of these services that regulates which 
diagnosis codes are appropriate to bill on ambulance claims. The Plan has not provided an applicable citation 
with this case, and therefore the denial of payment on this claim is not substantiated. Therefore, we decided that 
the Plan has to pay for the ambulance services (A0427, A0425) provided on September 13, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Home visit services provided on January 5, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Home visit services. You say that you would like to request reconsideration for 
payment. 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 Home visit services provided on January 5, 2022 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group three power wheelchair (PWC) and related 
accessories/features. 
 
You asked the Plan to pre-approve a group 3 PWC and features. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the member does not have a medical need for a Group 
3 power wheelchair (PWC) with the requested power options. As the requested Group 3 PWC with power 
options/features is not reasonable and necessary, none of the requested accessories can be covered. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 PWC with Single Power Option (K0856, 
K0857, K0858, K0859, K0860) or with Multiple Power Options (K0861, K0862, K0863, K0864) is covered if: 
    The Group 3 criteria IV(A) and IV(B) are met; and 
    The Group 2 Single Power Option (criteria II[A] and II[B]) or Multiple Power Options (criteria III[A] and 
III[B]) (respectively) are 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 a group 3 PWC and features. Our 
reviewer says that the items are not medically necessary. Our physician reviewer found the records do not 
document that the enrollee is at high risk for development of a pressure ulcer and is unable to perform a 
functional weight shift or she utilizes intermittent catheterization for bladder management and is unable to 
independently transfer from the wheelchair to bed or the power tilt is needed to manage increased tone or 
spasticity. 
 
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 PWC and features have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a group three power wheelchair (PWC) and related accessories/features.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 12, 2021. You asked the Plan to pay for the services provided. You say that the specimens are received from providers 
and are irreplaceable. The Plan denied your request. The Plan says the billed codes cannot be verified. 
 
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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab services provided on January 12, 2021.