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

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 24, 
2021, to October 25, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the inpatient services were 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 does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the provided documentation indicates that the enrollee stabilized quickly and was 
stable overall. Therefore, it was not expected that the enrollee would require hospital services that would likely 
cross 2 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 not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from October 24, 2021, to October 25, 
2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient mental health services provided from April 15, 2021, to 
May 4, 2021. 
 
You asked the Plan to pay for the outpatient mental health services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered. 
 
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. The Plan has provided no evidence showing that the enrollee was not enrolled in 
the Plan on the dates of service at issue in this appeal. The case file also has conflicting dates of when the 
enrollee was dis-enrolled. We are unable to make a determination based on the lack of evidence showing that 
the Plan's denial is correct based on Medicare criteria. Therefore, we decided that the Plan has to pay for the 
outpatient mental health services provided from April 15, 2021, to May 4, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Libtayo. 
 
You asked the Plan to pre-approve Libtayo. You say that  The Plan denied your request. The Plan says the 
requested treatment is not supported for the enrollee's type of cancer. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Libtayo. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the documentation does not support that 
the Libtayo is medically reasonable and necessary for the enrollee. The documentation does not support that 
Libtayo is safe and effective for the enrollee. The records show that the enrollee has a programmed death-
ligand 1 (PDL1) of 1% and non-small-cell lung carcinoma with progression on the drug Imfinzi. The requested 
use of Libtayo is not FDA approved for the enrollee's diagnosis with a PDL that is less than 50% and failure of 
a like drug. Use of Libtayo is also not supported by one of the major drug compendia or by lcinical research 
that appears in a CMS-approved medical journal in this scenario. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Libtayo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Libtayo.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an over-bed table (E0274). 
 
You asked the Plan to pre-approve an over-bed table. The Plan denied your request. The Plan says Medicare 
criteria for medical equipment do not cover an over-bed table. The Plan also says that an over-bed table is not 
for a medical problem and makes it easier for you to reach things. 
 
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 over-bed table (E0274).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance services provided to the enrollee on November 
12, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says covered ambulance services include fixed wing, rotary wing, and ground ambulance services, to 
the nearest appropriate facility that can provide care only if they are furnished to a member whose medical 
condition is such that other means of transportation could endanger the person's health or if authorized by the 
plan. 
 The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the 
documentation does not support that the patient suffers from an illness or injury that contraindicates 
transportation by any means other than ambulance. The documentation does not support that the patient's 
condition was such that the time needed to transport a patient by ground, or the instability of transportation by 
ground, posed a threat to the patient's survival or seriously endangered the patient's health. The documentation 
does not support that the transferring hospital did not have adequate facilities to provide the medical services 
needed by the patient. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for air ambulance services provided to the enrollee on November 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal knee-shin system, single axis, 
fluid swing and stance phase control (L5828), an addition, endoskeletal knee-shin system, stance flexion 
feature (L5845), an addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with 
or without adjustability (L5848) and an addition to lower extremity prosthesis, endoskeletal knee-shin system, 
microprocessor control feature, swing and stance phase, includes electronic sensor(s) (L5856). 
 
You asked the Plan to pre-approve prosthetics. You say that the requested items are needed as soon as possible 
to ensure the enrollee has mobility. The Plan denied your request. The Plan says while the vendor states that the 
enrollee requires a microprocessor knee, there are no notes from the enrollee's physician to support this or to 
show why a mechanical K3 knee cannot be used for the enrollee's initial prosthesis. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 an addition, endoskeletal knee-shin 
system, single axis, fluid swing and stance phase control (L5828), an addition, endoskeletal knee-shin system, 
stance flexion feature (L5845), an addition to endoskeletal knee-shin system, fluid stance extension, dampening 
feature, with or without adjustability (L5848) and an addition to lower extremity prosthesis, endoskeletal knee-
shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s) (L5856). 
have been met. The records show that the provider does not give any reason why a microprocessor knee is 
medically necessary for the enrollee. Therefore, we decided that the Plan does not have to pre-approve an 
addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control (L5828), an addition, 
endoskeletal knee-shin system, stance flexion feature (L5845), an addition to endoskeletal knee-shin system, 
fluid stance extension, dampening feature, with or without adjustability (L5848) and an addition to lower 
extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, 
includes electronic sensor(s) (L5856).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left-heart catheterization (93452). 
 
You asked the Plan to pre-approve a left-heart catheterization. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the 
requested service have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a left-heart catheterization. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee had a negative stress echocardiogram test in 2019, as well as another 
recent test, also negative, during which the enrollee exercised to a high level. The recent test showed no chest 
pains; electrocardiogram changes were noted but were non-specific. In the doctor's office, the enrollee had 
chest pain and no accompanying electrocardiogram changes. Guidelines do not support a need for cardiac 
catheterization in this 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 a left-heart catheterization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a left-heart catheterization (93452).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an epidural injection provided on November 8, 2021. 
 
You asked the Plan to pay for an epidural injection. The Plan denied your request. The Plan says the Health 
Plan has not received the required clinical records to support the medical necessity of the service for the date of 
service requested. The records provided are undated and unsigned. There is insufficient documentation of 
response to prior injections. 
 
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 an epidural injection provided on 
November 8, 2021 have been met. Therefore, we decided that the Plan does not have to pay for an epidural 
injection provided on November 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound services coded 76770 provided on April 29, 2021. 
 
You asked the Plan to pay for the ultrasound services. You say that the medical records support the services as 
billed. The Plan denied your request. The Plan says the documentation does not substantiate the services as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 76770 is ultrasound, retroperitoneal (eg, renal, aorta, 
nodes), real time with image documentation; complete. 
 
We asked our coder 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 ultrasound services. Our reviewer says that the 
documentation does not support payment for code 76770 as billed. Our reviewer found that the procedure 
report does not support a complete retroperitoneal ultrasound. Per CPT guidelines "real time scans of the 
kidneys, abdominal aorta, common iliac artery origins, and inferior vena vaca, including any demonstrated 
retroperitoneal abnormality".  Therefore, this procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ultrasound services have not been met. Therefore, we decided that the Plan 
does not have to pay for the ultrasound services coded 76770 provided on April 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the thyroid stimulating hormone (TSH) assay provided on 
August 5, 2021. 
You asked the Plan to pay for the TSH testing. You say that the testing was medically necessary and should be 
paid. The Plan denied your request. The Plan says all lab testing was approved on appeal, aside from the TSH 
testing which is not covered for screening purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that TSH testing may be considered reasonable and 
necessary for the indications listed in the Medicare rules section of this decision.  
 
We looked at the file and Medicare rules. There is no evidence of the presence of any covered indication for 
this testing. Based on this information, we decided that Medicare rules for coverage of the TSH testing have 
not been met. Therefore, we decided that the Plan does not have to pay for the thyroid stimulating hormone 
(TSH) assay provided on August 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement grafts (D7953 x3). 
 
You asked the Plan to pre-approve bone replacement grafts. You say that the requested service is medically 
necessary. The Plan denied your request. The Plan says the service at issue is not a covered benefit. 
 
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 pre-approve bone 
replacement grafts (D7953 x3).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller upgrade (E2377) harness upgrade 
for expandable controller (E2313) electronic connection between wheelchair controller and two or more power 
seating system motors (E2311) power seat elevation system (E2300) and footplate bracket (K0108). 
 
You asked the Plan to pre-approve the upgraded electronics, seat elevator and foot plate accessories. You say 
that the enrollee is currently unsafe to complete his MRADL's and will continue to be at high risk for falls and 
serious injury until his new chair is approved and delivered. The Plan denied your request. The Plan says the 
approved power options come with their own switches. The seat elevator does not serve a medical purpose and 
footplate bracket cannot be covered separately as the approved wheelchair already includes footplates with all 
parts needed. 
 
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 upgraded electronics, seat elevator 
and foot plate accessories. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the upgraded electronics are not medically 
necessary per Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504). The enrollee 
does not require non-proportional input devices (e.g., sip and puff, head array, etc.), a separate display (i.e., for 
alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer 
through the chair's drive control), or an attendant control. The enrollee has 3 power options of tilt, recline, and 
power elevating leg rests but the patient does not need to control the power options through a joystick. The 
enrollees upper extremity strength and function support that the patient can control any power options through 
their own switches. The footplates are already included in the approved power wheelchair and the power seat 
elevation system (E2300) is not covered by Medicare as it is not primarily medical in nature.  
 
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 upgraded electronics, seat elevator and foot plate accessories have not been 
met. Therefore, we decided that the Plan does not have to pre-approve expandable controller upgrade (E2377) 
harness upgrade for expandable controller (E2313) electronic connection between wheelchair controller and 
two or more power seating system motors (E2311) power seat elevation system (E2300) and footplate bracket 
(K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the POV, group 1 heavy duty, patient weight capacity 
301 to 450 pounds (CPT code K0801). 
 
You asked the Plan to pre-approve the POV. You say that the POV is necessary. The Plan denied your request. 
The Plan says the Medicare rules have not been met. 
 
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 POV have not been met. Review of the file shows the 
documented weight is 240 lbs. The request is for a heavy-duty wheelchair, patient weight capacity 301 to 450 
pounds. The member does not require a heavy-duty chair. Therefore, we decided that the Plan does not have to 
pre-approve the POV, group 1 heavy duty, patient weight capacity 301 to 450 pounds (CPT code K0801).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651, E0667) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the requested device is 
medically necessary. The Plan denied your request. The Plan says the requesting vendor for your device is not 
in your Plan's network. 
 
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 
a pneumatic compression device (E0651, E0667) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 22, 2021. 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
no medical necessity. The Plan denied your request. The Plan says the claim has not been billed in accordance 
with Medicare coding regulations. 
 
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 laboratory 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 laboratory services provided on July 22, 2021.