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

 
We decided that the Plan does not have to pay for the critical care services coded 99291 provided on November 
1, 2021. 
 
You asked the Plan to pay for the critical care 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation shows 
that the Plan was previously billed by and paid another provider for this service billed. This means this claim is 
not separately payable. Based on this information, we decided that Medicare rules for coverage of the critical 
care services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care 
services coded 99291 provided on November 1, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Retacrit (Q5106). 
 
You asked the Plan to pre-approve Retacrit. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says that the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Retacrit. Our reviewer says that the 
requested drug, Retacrit, is not medically necessary. Our physician reviewer found the Food and Drug 
Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition. The 
reviewer found that the Medicare approved drug compendia contain a supportive citation for the use of the 
requested drug in the enrollee's clinical situation. Therefore, the reviewer found that the requested drug is 
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 Retacrit have been met. Therefore, we decided that the Plan has to pre-approve 
Retacrit (Q5106).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on October 13, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that it is the facilities responsibility to obtain prior 
authorization and you would like the claim reprocessed for payment. The Plan denied your request. The Plan 
says the rendering provider is an OON provider and there was no referral from an in-network provider or an 
approved authorization. Also, the service rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a home health visit provided on October 13, 2021, 
by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Botox. Our reviewer says that the 
services are not medically necesssary. Our physician reviewer found based on the medical records provided 
and the Medicare-approved major drug compendia there is no documentation that the Botox meets Medicare 
criteria for safe and effective for the enrollee. The Medicare-approved major drug compendia do not cite 
gastroparesis as a medically-accepted indication for use of Botox. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on January 31, 
2022. 
 
You asked the Plan to pay for the x-ray 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 71045 is not supported in the medical record. Specifically, the documentation shows 
that this is a duplicate claim to one that was already considered for payment. Based on this information, we 
decided that Medicare rules for coverage of the x-ray services have not been met.  
 
 
 
 
 
  
Therefore, we decided that the Plan does not have to pay for the x-ray services coded 71045 provided on 
January 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve below knee prosthetics (L5301, L5940, L8470, L5620, 
L5629, L8420, L5637, L5980, L5645, L5647, L5655, L5668, L5679) to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve below knee prosthetics. You say that the current prosthetic you have is rigid 
and you suffer with pain making it difficult for you to do any daily life activities. The requested provider is the 
only provider that can do the prosthesis that you need. The Plan denied your request. The Plan says there are no 
extenuating circumstances making it medically necessary to obtain the services out-of-network. The Plan also 
says the requested prosthetics can be provided by an in-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 
below knee prosthetics (L5301, L5940, L8470, L5620, L5629, L8420, L5637, L5980, L5645, L5647, L5655, 
L5668, L5679) to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on July 20, 2021, 
and July 21, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this admission was justified. The Plan 
denied your request. The Plan says the patient's care could have been managed at an observation level of care, 
so inpatient admission was not 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 patient was a then 95-year-old female with a history of hypertension, diabetes 
mellitus, and congestive heart failure (CHF) with ejection fraction of 30% who presented to the emergency 
room (ER) with shortness of breath. The ER evaluation revealed hemodynamic stability with evidence of CHF; 
brain natriuretic peptide testing was elevated to 1200. There were no acute EKG changes noted. She was 
treated with supplemental oxygen and IV diuretics. She was admitted and evaluated by Cardiology. Her 
medical regimen was adjusted; her condition stabilized and improved, and she was discharged the next day 
with outpatient follow-up. 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 ER 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 not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on July 20, 2021, and July 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiology (heart transplant), mRNA gene profiling of 30 
genes (81595) provided on December 20, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration of the 
denied claim for AlloMap, billed under CPT code 81595. The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 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 the cardiology (heart transplant), mRNA gene 
profiling of 30 genes (81595) provided on December 20, 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 a wheelchair ramp. 
 
You asked the Plan to pre-approve a wheelchair ramp. You say that you cannot safely get out of the house. The 
Plan denied your request. The Plan says it is not primarily medical in nature. 
 
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 a wheelchair ramp.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia provided on September 23, 2021. 
 
You asked the Plan to pay for anesthesia. You say that the provider was certified and eligible to perform 
anesthesia on this date of service. You say that the claim should be considered for payment. The Plan denied 
your request. The Plan says that anesthesia codes can only be reimbursed to anesthesia providers. 
 
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 not provided a valid rationale for why the rendering provider type 
is not appropriate for anesthesia services. It is the burden of the Health Plan to substantiate their denial with 
evidence. In this case, the denial has not been substantiated so we must find in your favor. Therefore, we 
decided that the Plan has to pay for anesthesia provided on September 23, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept Procedure. 
 
You asked the Plan to pre-approve the Intracept Procedure. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept Procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has low back pain. The intracept procedure is experimental. More 
research is needed to show safety and efficacy. Therefore, the enrollee does not meet criteria for the requested 
services. 
 
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 Intracept Procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept Procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, a computed tomography, of the maxillofacial 
area and diagnostic imaging of the head and neck provided from November 18, 2021, through 
December 9, 2021. 
 
You asked the Plan to pay for an office visit, a computed tomography, of the maxillofacial area and diagnostic 
imaging of the head and neck. You say that the services should be covered. The Plan denied your request. The 
Plan says you received the service from a provider who chose not to receive Medicare funds. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an office 
visit, a computed tomography, of the maxillofacial area and diagnostic imaging of the head and neck provided 
from November 18, 2021, through December 9, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says custodial care is not a covered benefit. 
 
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 the admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found you have 
stabilized medically and have been receiving skilled rehab services in an inpatient rehabilitation facility 
(IRF). You have tolerated inpatient rehab services and continue to improve with daily skilled nursing and/or 
skilled therapy services. You could benefit from continued services at the current level of care. You have made 
slow progress with therapy, and there is no indication that transfer to a skilled nursing facility is required. You 
can continue to receive skilled rehab services at the current IRF or be stepped down to a lower level of care 
when appropriate. There are no services offered at a SNF that are not offered at an inpatient rehab 
facility. 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 the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
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 you are appealing with supporting records. The Plan 
denied your request. The Plan says the information they have been provided with does not show that the 
enrollee needs a doctor trained in rehabilitation to supervise the therapy and be seen 3 times per week. The Plan 
also says that admission to an inpatient rehabilitation facility is denied as not medically necessary at this time. 
 
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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician 
reviewer also found that the patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Potassium Chloride tablet. 
 
You asked the Plan to pre-approve Potassium Chloride tablet. You say that this drug is medically reasonable 
and necessary. The Plan denied your request. The Plan says this drug is not covered under the enrollee's 
medical benefit. 
 
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 Potassium Chloride tablet.  
 
Benefits for Potassium Chloride tablet 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 a home mechanical ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the request for a home mechanical ventilator set in intelligent volume-assured 
pressure support (iVAPS) mode with Auto-EPAP (AE) that could be delivered by bilateral positive airway 
pressure (BiPAP) is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found a home 
ventilator is not medically reasonable or necessary. You have severe chronic obstructive pulmonary disease 
(COPD), but there is no documentation of chronic CO2 retention with an arterial blood gas study (ABG) done as an outpatient while stable. The average volume-assured pressure support (AVAPS) can be delivered via 
bilateral positive airway pressure (BiPAP), and Medicare does not cover a home ventilator used as BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home mechanical ventilator.