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

 
We decided that the Plan does not have to pay for Genetic Testing provided on September 9, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Genetic Testing. You say that the in-network doctor ordered tests for the patient. 
The Plan denied your request. The Plan says the provider is out-of-network and there are no documents 
showing that these services were 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 Genetic Testing provided on September 9, 2021 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve rental of the intrapulmonary percussive device, the 
Volara respiratory system (CPT code E1399). 
 
You asked the Plan to pre-approve the device. You say that the device is medically necessary. The Plan denied 
your request. The Plan says there is little evidence in the medical literature to suggest that this is an appropriate 
treatment for the enrollee's lung issues. The Plan states it is not an accepted standard of medical practice for the 
treatment of chronic obstructive pulmonary disease (COPD). The Plan states it is considered experimental and 
investigational. The Plan states given the enrollee's memory, agitation, and compliance problems it is not clear 
that the enrollee would be able to use this device. 
 
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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Volara System is not medically necessary. This patient has COPD and obstructive sleep 
apnea (OSA) and is confused and disoriented.  The enrollee has a Trilogy ventilator but has been noncompliant 
with its use. There is no diagnosis of cystic fibrosis, bronchiectasis, or neuromuscular disease. The Volara 
System combines intra-airway percussive ventilation, end-expiratory pressure, and nebulization. There is inadequate evidence for effectiveness in any lung condition, including COPD. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve rental of the intrapulmonary percussive device, the Volara respiratory system (CPT code 
E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve the supplemental benefits. You say that SSBCI is necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee does not have a need for intensive case management, 
is not a high risk for hospitalization with diagnosis of neurological/epilepsy/polyneuropathy; therefore, the 
enrollee does not meet the requirements for the SSBCI program. 
 
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 supplemental benefits. Our 
physician reviewer found that the enrollee does not meet the criteria for SSBCI. The enrollee does not have one 
or more conditions (as listed on pages 57-58 of the EOC) that is life threatening or significantly limits their 
health or function. The enrollee is not a high risk for hospitalization. The enrollee does not require intensive care coordination. 
 
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 supplemental benefits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is a high risk for falls, injury and 
admission to acute care. You say that the enrollee's services cannot be safely met with home health services or 
a skilled nursing facility and authorization for inpatient rehabilitation should be granted. The Plan denied your 
request. The Plan says the medical records do not support the need for an intensive rehabilitation therapy 
program. 
 
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 that the enrollee does not require close supervision 3 times per week and no rehab 
nursing needs were identified or documented in the record. While the enrollee may benefit from physical or 
occupational therapy, the enrollee's rehab can be safely provided in alternate setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee has been unsteady. The Plan denied 
your request. The Plan says the enrollee does not require daily skilled services on an inpatient basis. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer 
found that the enrollee was admitted to the acute care hospital for an acute disease with septic shock and a 
mechanical fall. The most recent therapy documentation indicates she is able to ambulate up to 150 feet and is 
able to accomplish bed mobility and transfers with modified independence to supervision. Her physical 
function is at or near her baseline. She is medically stable and does not have any complex daily wound care, 
parental medications or required care for a new or malfunctioning feeding tube. She is without any acute 
exacerbations of chronic medical problems. An admission to a SNF for inpatient skilled rehab services 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on January 21, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that these services were ordered by the enrollee's 
physician. 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 the ordering physician was also out-of-network with 
the Plan. 
 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 drug testing provided on January 21, 2022 by an 
out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve Eliquis. You say that the enrollee is on this medication for stroke 
prevention. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by 
Medicare 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 Eliquis.  
 
 
 Benefits for Eliquis 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthopedic footwear (L3215) and a shoe lift (L3320). 
 
You asked the Plan to pre-approve orthopedic footwear and a shoe lift. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says these items are not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve orthopedic footwear (L3215) and a 
shoe lift (L3320).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fecal occult testing (82270) provided on January 24, 
2022. 
 
You asked the Plan to pay for the fecal occult testing. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this benefit has been exhausted. 
 
The Plan must follow Medicare rules. Medicare rules say that screening FOBT [fecal-occult blood test] 
(82270) (G0107) may be paid for beneficiaries who have attained age 50, and at a frequency of once every 12 
months. 
 
We looked at the file and Medicare rules. In this case, the documentation shows that FOBT services were 
previously filed on a claim dated January 20, 2022. Therefore, the benefit has been exhausted for the services 
for January 24, 2022. Based on this information, we decided that Medicare rules for coverage of the fecal 
occult testing have not been met. Therefore, we decided that the Plan does not have to pay for the fecal occult 
testing (82270) provided on January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ophthalmologist appointment to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the ophthalmologist appointment. You say that you had a bad experience 
with an in-network provider, and you would like to see a different provider. The Plan denied your request. The 
Plan says they referred you to a different in-network provider that provides the same quality of service as the 
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 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 
an ophthalmologist appointment to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the POC (CPT code E1392). 
 
You asked the Plan to pre-approve the POC. You say that without enough oxygen, your oxygen level has the 
risk of dropping down to a terminal level. You state that you need this as soon as possible to prevent this from 
happening. You state that you have exhausted all other options to find a portable oxygen concentrator, and 
nobody can provide you with one that accepts your health plan. The Plan denied your request. The Plan says 
you are requesting purchase of an Inogen concentrator due to breathing problems; however, Medicare says that 
purchased oxygen equipment is statutorily non-covered. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the POC have not been met. Your request is not a covered benefit 
because Medicare does not cover purchased oxygen equipment and your oxygen needs can be provided by 
rental of approved equipment. Therefore, we decided that the Plan does not have to pre-approve the POC (CPT 
code E1392).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after May 
4, 2022. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs additional time to get support in 
place to safely go home. The Plan denied your request. The Plan says the denial of authorization for continued 
SNF care is correct. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued skilled nursing facility (SNF) care after May 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve enteral formula (B4161). 
 
You asked the Plan to pre-approve enteral formula. You say that this is medically necessary for your food 
intolerance issues. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that enteral nutrition is covered for a beneficiary who 
requires feedings via an enteral access device. Based on this information, we decided that Medicare rules for 
coverage of enteral formula have not been met. Therefore, we decided that the Plan does not have to pre-
approve enteral formula (B4161).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on December 
6, 2021. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you cannot pay this bill. The Plan 
denied your request. The Plan says this service is not a covered expense under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
periodontal maintenance (D4910) provided on December 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the stationary oxygen tank (E0424). 
 
You asked the Plan to pre-approve the stationary oxygen tank. You say that the item should be covered. The 
Plan denied your request. The Plan says the clinical documentation received states that the H (stationary) 
oxygen tank requested by your physician is for preventive or precautionary purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 stationary oxygen tank have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the stationary oxygen tank (E0424).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an exercise bike. 
 
You asked the Plan to pre-approve an exercise bike. You say that this is necessary for you to exercise inside 
your home. The Plan denied your request. The Plan says this item is not covered by Medicare or by the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an exercise bike.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retroperitoneal ultrasound (76770) provided on October 
27, 2021. 
 
You asked the Plan to pay for the retroperitoneal ultrasound. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 76770 
and 93976. 
 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 76770 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 retroperitoneal ultrasound (76770) provided on October 27, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-preferred brand for diabetic supplies. 
 
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says the 
documentation does not show that the enrollee cannot use the preferred test strips or meters. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan will not cover other brands unless the provider says it is medically necessary. 
 
We looked at the file and the rules. The requested brand of diabetic supplies is not a preferred brand with the 
Plan. The Plan has preferred brands available who can provide the items at issue in this appeal.  We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the 
Plan does not have to pre-approve a non-preferred brand for diabetic supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services, provided on October 20, 2021, to 
November 22, 2021. 
 
You asked the Plan to pay for the chiropractic services. You say that the service is medically necessary. The 
Plan denied your request. The Plan says chiropractic services other than the manual subluxation of the spine are 
not covered. 
 The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the chiropractic services, provided on October 20, 2021, to November 22, 
2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on October 6, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you 
tripped, and a third party called the ambulance. You also say that when they arrived, they took your blood 
pressure and pulse and asked if you needed to go to the hospital, and you replied no. The Plan denied your 
request. The Plan says your plan covers ambulance transportation only when you are actually transported by 
ambulance. The Plan also says that since you were not transported by ambulance, the service is not covered by 
your plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 6, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on October 6, 2021.