Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital care provided for hip replacement revision 
surgery from February 1, 2022, through February 3, 2022. 
 
You asked the Plan to pay for the inpatient hospital care. You say that this is a medically necessary procedure 
that was billed as inpatient as the procedure is inpatient-only. The Plan was aware of the urgent admission and 
did not indicate that authorization would be required for inpatient admission. The Plan denied your request. 
The Plan says that the facility failed to notify the health plan of inpatient admission. The contract with the 
enrollee states that to be an inpatient, the provider must write an order to admit the enrollee formally as an 
inpatient of the hospital. 
 
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. In this case, the enrollee presented to the facility after multiple falls and hip 
dislocation. The admission note indicates that the enrollee was scheduled for a non-elective, urgent revision 
due to ongoing issues with her hip prothesis. As such, the argument that no authorization was requested for the 
inpatient admission is not valid, as authorization cannot be required for an urgent, non-elective surgery. It is 
also notable that there does appears to have been contact between the facility and the Plan at the time these 
services were initiated. 
 
Though originally billed as an outpatient procedure, the facility did acknowledge the inpatient-only nature of 
this surgery and re-billed as an inpatient claim. The Plan also indicates a lack of a formal admission order to 
support non-coverage. Though the records submitted do not include a list of the orders issued during this stay, 
the records do appear to reflect that the enrollee was in inpatient status. There is no evidence that the Plan 
attempted to request a copy of the order. Based on the entirety of the evidence, we find that the denial of 
payment for this inpatient stay has not been substantiated. Therefore, we decided that the Plan has to pay for 
the inpatient hospital care provided for hip replacement revision surgery from February 1, 2022, through 
February 3, 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx (F1CDx) testing provided on September 28, 
2021. 
 
You asked the Plan to pay for the F1CDx panel. You say that this is an FDA-approved test that is covered by 
Medicare. The Plan denied your request. The Plan says that there is a Local Coverage Determination (LCD) 
that indicates that any panel that tests for the FANCC gene is noncovered. Since this panel includes that, the 
denial is correct. 
 
We reviewed the LCD cited by the Plan but find that it is not applicable to an FDA-approved test, as these are 
covered via the NCD cited in the Medicare rules section. An LCD cannot limit coverage allowed by an NCD, 
per the Medicare hierarchy of authority. As such, we disregarded the LCD cited by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, such as the F1CDx panel, when provided for an FDA-approved indication. 
 
We looked at the file and Medicare rules. This testing was provided to a patient with a solid tumor. The FDA 
approval notice indicates that this panel is approved for breast cancer and all solid tumors. The test was 
performed on tumor tissue from the breast in the setting of new secondary bone metastasis. No other valid 
denial rationale was presented by the Plan. Based on this information, we decided that Medicare rules for 
coverage of the F1CDx testing have been met. Therefore, we decided that the Plan has to pay for the 
FoundationOne CDx (F1CDx) testing provided on September 28, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
sensor and supplies (K0553, K0554). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM sensor and supplies. You say that your health is at 
risk, and you need your diabetic sensors. The Plan denied your request. The Plan says you are currently 
enrolled in hospice. The treatment of diabetes is related to your hospice diagnosis, and it is not covered by the 
Plan. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
 
 The enrollee is under the Medicare hospice benefit as of March 1, 2022. Therefore, we decided that the Plan 
does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) sensor and supplies 
(K0553, K0554).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from 
February 26, 2022, through March 7, 2022. 
 
You asked the Plan to pay for the provided SNF care. You say that you would like this SNF care reprocessed 
and approved for payment. The Plan denied your request. The Plan says the provided SNF care was not 
medically reasonable and necessary.  
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 pay for the provided SNF care. Our reviewer says 
that the SNF care provided on the dates in question was not medically reasonable and necessary. Our physician 
reviewer found the enrollee is a 66-year-old female with a history of hypertension, diabetes mellitus, ureteral 
stent and breast cancer. In this case, the enrollee no longer qualified for SNF coverage. The enrollee did not 
have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily 
skilled services were not required to establish a maintenance program or to prevent deterioration of the 
enrollees condition. The enrollees care needs could, as a practical matter, have been provided at a lower level 
of 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 the provided SNF care have not been met. Therefore, we decided that the Plan 
does not have to pay for the skilled nursing facility (SNF) care provided from February 26, 2022, through 
March 7, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 the 
service is not medically necessary. Our physician reviewer found you are functioning at a home care level. A 
person is able to progress at CGA with repetitive exercise and support from a non-skilled person. This is quite 
clear with the review of occupational therapy intervention which consists of repetitive strengthening activities 
with a theraband not ADL training. Per Chapter 8 of the Medicare Benefit Manual, criteria are not met as the 
requested services are not necessary for your condition. 
 
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 skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Yervoy. 
 
You asked the Plan to pre-approve Yervoy. You say that this drug is medically reasonable and necessary. The 
Plan denied your request. The Plan says the criteria for coverage have not been satisfied. 
 
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 Yervoy. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee has been 
diagnosed with large cell neuroendocrine cancer uterus. They have had previous progression on Keytruda. 
Immunotherapy has been tried and failed and the provider notes they wish to prescribe this drug based on 
compassionate use. In this case, this drug is not FDA-approved for the enrollee's condtiion and is not 
compendia nor literature supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Yervoy have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Yervoy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthotic (L3960) provided 
March 31, 2022. 
 
You asked the Plan to pay for the orthotic. You say that this claim met all of Medicare's DME LCD coverage 
criteria. The Plan denied your request. The Plan says The services are not supported in the medical records 
received. 
 
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 the orthotic. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided documentation did not clearly show the reason for using this brace such as having 
had a recent or planned surgery, having objective instability, or other indication for bracing. Bracing is not supported to treat joint pain alone. Therefore, this request for the shoulder brace will be considered not 
medically necessary based on the provided documentation. 
 
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 orthotic have not been met. Therefore, we decided that the Plan does not 
have to pay for the shoulder-elbow-wrist-hand orthotic (L3960) provided March 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the Medicare Part B drugs and the 
outpatient hospital procedure you received on February 15, 2022. 
 
You asked the Plan to waive the cost sharing for the Part B drugs and the outpatient hospital procedure. You 
say that you have a rare blood condition and feel you should not be charged the outpatient copayment because 
your condition almost always has you hospitalized because of bleeding. The Plan denied your request. The Plan 
says you were charged these cost sharing amounts 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 20% 
coinsurance for Medicare Part B drugs and a $375 copayment for procedures in an outpatient hospital facility.  
 
You have been asked to pay 20% coinsurance for the Part B drugs and a $375 copayment for the outpatient 
hospital procedure. These cost sharing amounts apply because these services were performed in a hospital in an 
outpatient setting.  You were not admitted as an inpatient, regardless of what may have occurred in the past. 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 cost sharing for the Medicare Part B drugs and the outpatient hospital 
procedure you received on February 15, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the gauze, non-impregnated, sterile, pad size 16 sq. in. or less, with any 
size adhesive border, each dressing (A6219) provided August 12, 2021. 
 
You asked the Plan to pay for the wound care supplies. You say that you disagree with the denial. Medicare 
allows up to three times per day. You have enclosed medical records along with the Medicare LCD. This claim 
should be reprocessed and paid. The Plan denied your request. The Plan says that the claim was reimbursed in 
accordance with the maximum allowable units. 
 
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. specific records or information was required to substantiate the plans denial. The 
required information was missing from the original file. A request for information was sent to the health plan 
on August 11, 2022 with a due date of August 12, 2022. As of the date of this letter, the plan has not responded 
to our request and/or submitted the required information. Therefore, we decided that the Plan has to pay for the 
gauze, non-impregnated, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing 
(A6219) provided August 12, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 the 
service is not medically necessary. Our physician reviewer found the lack of change in response to intensive 
therapy indicates an impaired capacity to respond to less intensive daily skilled therapy in a SNF with 
materially significant gains within a predictable time frame. The enrollee's condition has not responded as 
expected to therapy. He has no daily skilled nursing needs. Criteria per chapter 8 not met as the requested 
service is not necessary or effective for the enrollee's condition to either restore or maintain function. 
 
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 skilled nursing facility (SNF) care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 4, 2021, 
through October 31, 2021, billed with code 1CFMS. 
 
You asked the Plan to pay for the home health services as billed. You say that the Plan provided verbal 
confirmation before services began. Since this Plan pays as Medicare, this should not be denied. The Plan 
denied your request. The Plan says this was billed with an invalid HIPPS code for the date range at issue. 
 
The Plan must follow Medicare rules. Medicare rules say that as of January 1, 2020, Medicare revised home 
health payments and instituted new HIPPS codes.  
 
We looked at the file and Medicare rules. The HIPPS code reported in this case is no longer valid for services 
provided after January 1, 2020. The fact that the Plan was notified of the services does not change how 
rendered services are required to be billed. Based on this information, we decided that Medicare rules for 
coverage of the home health services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the home health services provided from October 4, 2021, through October 31, 2021, billed with 
code 1CFMS.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from December 7, 2021, to 
December 28, 2021. 
 You asked the Plan to pay for the home health services. You say that these services should be paid. The Plan 
denied your request. The Plan says the records do not meet criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer says 
that criteria for coverage of home health services were not met on these dates. Our physician reviewer found 
the records do not indicate that the patient had ongoing skilled nursing needs on these dates or that the patient 
still qualified for homebound status. 
 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for home health services provided from December 7, 2021, to December 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the folding wheeled walker (E0143), the 
sales tax (S9999), the adult disposable incontinence products (T4544), the disposable underpads (T4541), 
unlisted special service (99199), the set up and delivery of durable medical equipment (A9901), and the shower 
chair (E0240) provided from August 14, 2021, through October 4, 2021. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as the 
provider in this case is not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to issue reimbursement for the folding wheeled 
walker (E0143), the sales tax (S9999), the adult disposable incontinence products (T4544), the disposable 
underpads (T4541), unlisted special service (99199), the set up and delivery of durable medical equipment 
(A9901), and the shower chair (E0240) provided from August 14, 2021, through October 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve noc for enteral supplies (B9998). 
 
You asked the Plan to pre-approve noc enteral supplies. You say that you are currently eating out of a tube and 
need to use certain type of bags. You also say that you need the gravity bags, syringes and gauze, for survival. 
The Plan denied your request. The Plan says your request is not medically necessary because your supply 
allowance includes funding for the Y-connectors, and they are not permitted to be billed separately from the 
supply allowance. 
 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 B9998 is noc for enteral supplies. 
 
We find that CPT code B9998 is not supported in the medical record. Specifically, you cannot report B9998 
separately from the supply allowance. Based on this information, we decided that Medicare rules for coverage 
of enteral supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve noc for 
enteral supplies (B9998).