Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Group 3 power wheelchair with single power option. 
 
You asked the Plan to pre-approve the requested wheelchair. The Plan denied your request. The Plan says that 
power elevating leg lifts are not reasonable or necessary. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications.  
 
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 requested wheelchair. Our physician 
reviewer found that the enrollee has a past medical history of Parkinsons disease, stroke with left sided 
weakness, lower limb edema and multiple falls. Authorization for group 3 power wheelchair with single power 
option is being requested. The clinical documentation states that the enrollee has motor weakness and is not 
appropriate for other assistive devices with multiple falls (manual wheelchair, walker, cane). The Plan agrees 
that she meets criteria for group 3 power wheelchair. The documentation along with evaluating therapist states 
that she requires power elevating leg lifts due to edema and inability to reposition lower limbs. Thus, this 
power function is also medically necessary. 
 
The file shows that a privacy flap was requested does not serve a purpose that is primarily medical in nature. 
The file also shows that 2 batteries were requested. A sealed battery (E2361) is separately payable from a 
power wheelchair base. However, an additional battery is not considered necessary. If DME serves the same 
purpose as equipment already available to an enrollee, it is not considered reasonable and 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 requested wheelchair have been met. Therefore, we decided that the Plan 
has to pre-approve a Group 3 power wheelchair with single power option.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda for the enrollee. 
 
You asked the Plan to pre-approve Keytruda. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the documentation does not support that the member has PDL-1 positive NSCLC. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Keytruda. Our reviewer says that 
Keytruda is not medically reasonable and necessary. Keytruda is not FDA-approved for the enrollees 
diagnosis as a single agent with no PD-L1 status. The use of Keytruda is not supported by one of the major 
drug compendia or by clinical research that appears in a CMS-approved medical journal. Our physician 
reviewer found that the enrollee's condition does not meet criteria for coverage of Keytruda. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 2, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 the laboratory services are not supported in the medical record. Specifically, if a laboratory assays 
two or more genes in an enrollee in parallel, those two or more genes will be considered part of the same panel. 
A panel constitutes a single procedural service so one code must be submitted for the panel. Review of the file 
does not support that one code was billed for this panel. Based on this information, we decided that Medicare 
rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not 
have to pay for the laboratory services provided on November 2, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cologuard test (81528) for cancer screening. 
 
You asked the Plan to pre-approve a Cologuard test. You say that you wonder how long the age bracket of ages 
50 to 85 have been in place, since the life expectancy figures have been rising in recent years. You also say that 
you are the main caregiver in your house, and it would create a great hardship on your family if you were 
unable to continue. The Plan denied your request. The Plan says you are 89 years old and symptomatic with 
iron deficiency anemia presumed to be due to gastrointestinal blood loss. The Plan also says that there is no 
documentation of a guaiac test, digital rectal exam or an evaluation for iron deficiency, and there is no reported 
contraindication for a colonoscopy. 
 
The Plan follows Medicare rules. Medicare rules say that the Cologuard test is covered once every three years 
for Medicare beneficiaries that meet all of the criteria listed 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 a Cologuard test. Our reviewer says that 
you do not meet the guidelines for coverage for a Cologuard test. Our physician reviewer found you are over 
85 years old, and have iron deficiency which puts you at high risk for colon cancer and warrants a colonoscopy. 
 
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 Cologuard test have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Cologuard test (81528) for cancer screening.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital care provided from February 2, 2020, to February 10, 
2020, at the submitted Diagnosis Related Group (DRG) rate. 
 
You asked the Plan to pay for inpatient hospital care at the original DRG rate. You say that this claim has been 
underpaid. The Plan denied your request. The Plan says that this claim has been corrected internally and has 
been adjusted for an overpayment. 
 
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. Based on the limited information submitted, it appears that this is a payment 
issue related to a submitted DRG rate being changed after Plan audit. It appears that the claim was submitted 
with DRG 040 and the Plan changed the DRG to 085 (or vice versa, as the documentation is not clear). The 
Plan has provided no clear argument or explanation for this change, nor have they provided any citation to 
support any argument. In addition, no medical records were provided to support the Plans decision. Therefore, 
we decided that the Plan has to pay for inpatient hospital care provided from February 2, 2020, to February 10, 
2020, at the submitted Diagnosis Related Group (DRG) rate.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that therapy with a medical team is the recommended 
care that is best for the enrollee. The Plan denied your request. The Plan says the denial of authorization for 
IRF care is correct. 
 
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. While the 
enrollee may need physical and/or occupational therapy, there is no documented need for an intensive 
rehabilitation therapy 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
August 27, 2020, to August 28, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this should be paid for. The Plan 
denied your request. The Plan says it cannot be determined how the enrollee came to the servicing provider, or 
whether the services are medically necessary. 
 
 
 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the review has determined that the record did not show that at the time of inpatient 
admission the admitting physician reasonably expected that the patient's necessary hospital care (including 
earlier ED and/or observation care) would span two midnights. The enrollee remained stable post-operatively. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services provided to the enrollee from August 27, 2020, to 
August 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on 
September 24, 2021. 
 
You asked the Plan to pay for the moderate sedation services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this is a duplicate claim 
that has already been considered for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the moderate sedation services (99153) 
provided on September 24, 2021, have been met. In this case, the claim has denied payment with the Plan 
stating that the service was a duplicate to what has already been paid. No medical records were provided from 
the appellant to argue that the services were not a duplicate to what was paid. Therefore, we decided that the 
Plan does not have to pay for the moderate sedation services (99153) provided on September 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ER/PR/HER2 KI-67 and p53 testing rendered on August 
10, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the documentation does not support that 
Ki-67 and p-53 testing was medically reasonable and necessary. It has not been demonstrated that this testing 
meets, but does not exceed, the enrollee's medical need, and that the tests are at least as beneficial as an existing 
and available medically appropriate alternatives. It has not been shown that this testing is an accepted standard 
of medical practice for the diagnosis or treatment of the enrollee's condition. There is a lack of support for this 
testing in national oncology guidelines. 
 
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 pay for the ER/PR/HER2 KI-67 and p53 testing rendered on August 10, 2021.
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 enrollee is stable and appropriate for 
transfer to LTACH. The Plan denied your request. The Plan says the denial of authorization for LTACH care is 
correct. 
 
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 that have not been denied. The 
record does not indicate that the enrollee requires services at the LTACH that are not available at the current 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scans of extremity veins including responses to 
compression and other maneuvers (97930) provided on February 4, 2022 to February 8, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the diagnostic services. You say that the services should be covered. The Plan 
denied your request. The Plan says prior authorization was not obtained before the services were rendered. The 
Plan also says that the services were not urgent or emergent in nature. 
 
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 provider in this case is not a network provider with the Plan. The Plan did not pre-approve the diagnostic 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 the duplex scans of extremity veins including responses to 
compression and other maneuvers (97930) provided on February 4, 2022 to February 8, 2022 by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the culture services coded 87150 provided on July 22, 2021. 
 
You asked the Plan to pay for the culture services. You say that you would like the plan to reconsider their 
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 lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the culture services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the culture services coded 87150 provided on July 22, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from January 17, 2022, to 
January 20, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that an 
inpatient admission was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee was admitted for altered mental status, COVID-19 infection, and urinary tract 
infection. Altered mental status persisted and she had an episode of aspiration. The record shows that at the 
time of inpatient admission the admitting physician reasonably expected that the enrollees necessary hospital 
care (including earlier emergency department and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from January 17, 2022, to January 20, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for an eyewear accessory and/or service component charge (code V2797) 
and eyewear provided on February 11, 2022. 
 
You asked the Plan to pay for eyewear. You say that routine eye exams are covered under your plan. The Plan 
denied your request. The Plan says that the denial of payment for this charge is correct, because you do not 
have coverage for optional warranties and the refraction is inclusive in the routine examination. 
 
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. Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a 
routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules 
apply in this case. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not submit a detailed description or record to identify the item or 
service that constituted charge code V2797. Code V2797 represents an eyewear accessory or component. Your 
contract with the Plan covers eyewear up to $300 once per calendar year. Without a detailed description of 
code V2797, we cannot determine whether this charge is included in your eyewear benefit. Therefore, the Plan 
has not shown that its decision to deny payment for this charge is correct or justified according to your contract 
with the Plan. Therefore, the total covered charge for eyewear on this claim is $384.83. Furthermore, the Plans 
eyewear benefit covers up to $300; however, the Plan only paid $180 total the eyewear charges on this claim. Therefore, the Plan must pay an additional $120 to fulfill your covered eyewear benefit. Therefore, we decided 
that the Plan has to pay for an eyewear accessory and/or service component charge (code V2797) and eyewear 
provided on February 11, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.