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

 
We decided that the Plan does not have to pay for lab services provided on May 11, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 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 lab 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 lab services provided on May 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 28, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
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 lab 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 lab services provided on May 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the COVID-19 testing provided on 
October 25, 2021. 
 
You asked the Plan to provide reimbursement for the COVID-19 testing. You say that you are on a fixed 
income and cannot afford to pay for this test. You believe that it should be reimbursed by the Plan. The Plan 
denied your request. The Plan says this test was not provided due to symptoms or potential exposure. This test 
was required by a third party in order to fly to another country. 
 
The Plan must follow Medicare rules. Medicare rules say that examinations required by third parties are not 
covered by Medicare.  
 
We looked at the file and Medicare rules. This testing was not ordered by a doctor due to symptoms or 
exposure. This was required by a third party for non-medical reasons. Based on this information, we decided 
that Medicare rules for coverage of the COVID-19 testing have not been met. Therefore, we decided that the 
Plan does not have to provide reimbursement for the COVID-19 testing provided on October 25, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient services provided from June 18, 2021, through June 24, 2021 
with the secondary diagnosis toxic encephalopathy, code G92. 
 
You asked the Plan to pay for the inpatient services provided from June 18, 2021, through June 24, 2021 with 
the secondary diagnosis toxic encephalopathy, code G92. The Plan denied your request. The Plan says that the 
enrollee did not exhibit altered level of consciousness or cognition. While she may have experienced an episode of 
delirium, with hallucination, in the overnight hours of June 19, 2021, to June 20, 2021, she did not exhibit manifest 
encephalopathy, toxic or otherwise. 
 
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 us with the required medical records. Therefore, we 
decided that the Plan has to pay for inpatient services provided from June 18, 2021, through June 24, 2021 with 
the secondary diagnosis toxic encephalopathy, code G92.  
 
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 reduce the copayment for an aspiration biopsy provided on 
December 14, 2021. 
 
You asked the Plan to reduce the copayment for an aspiration biopsy. You say that your procedure was done at 
a standalone surgical center not at a hospital. You also say that you should not be charged a full outpatient 
hospital copayment just because the billing is done through the hospital. The Plan denied your request. The 
Plan says you have been charged the correct cost sharing amount. 
 
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 a $300 
copayment for outpatient hospital surgery.  
 
The record shows that the facility your procedure was rendered at is affiliated and part of the hospital. 
Therefore, it is not an ambulatory surgical center. You have been asked to pay a $300 copayment for an 
aspiration biopsy. An aspiration biopsy falls within the Outpatient Hospital Services benefit category. 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 reduce the copayment for an aspiration biopsy provided on December 14, 2021.  
 
Your complaint about being given incorrect information is not a valid appeal for medical coverage. This part of 
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Arformoterol tartrate (J7605). 
 
You asked the Plan to pre-approve Arformoterol tartrate. You say that the requested drug is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not 
been met. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Arformoterol tartrate. Our reviewer 
says that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer 
found that the Plan requires a trial of Perforomist before they will approve the requested drug.  The requested 
medication is a new start. The provided records do not indicate that the enrollee has tried and failed the Plan's 
preferred step-one alternative. The record does not indicate that the enrollee has a contraindication to, or would 
have an adverse effect from, the Plan's preferred step-one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Arformoterol tartrate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve treatment with Arformoterol tartrate (J7605).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 14, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
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 lab 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 lab services provided on July 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 25, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
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 lab 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 lab services provided on May 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 11, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
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 lab 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 lab services provided on July 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 10, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed an incorrect place of service on the claim. 
 
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 lab 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 lab services provided on April 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electronic connection and armrest downposts. 
 
You asked the Plan to pre-approve the electronic connection and armrest downposts. You say that you would 
like reconsideration based on the records submitted. The Plan denied your request. The Plan says the requested 
equipment is 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 electronic connection and armrest 
downposts. Our reviewer says that based on the medical records provided there is no documentation that it is 
medically necessary for the enrollee to control the approved power options through the joystick, as defined by 
Medicare criteria. Provided records document that the enrollee has normal fine motor coordination skills, 4/5 
bilateral upper extremity strength and is independent with feeding and grooming thus indicating she has 
adequate upper extremity strength and function to operate the wheelchairs power options with their own 
switches. 
 
Our physician reviewer found there is no documentation that the requested armrests meet Medicare criteria for 
medically necessary in place of the armrests that are included with the group 3 power wheelchair. Provided 
medical records do not clarify why the armrests that are included with the group 3 power wheelchair are 
inadequate to meet the enrollee's needs. 
 
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 electronic connection and armrest downposts have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the electronic connection and armrest downposts.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Volara high frequency chest wall oscillation device 
(E1399). 
 
You asked the Plan to pre-approve the Volara device. You say that patients like the enrollee have tried and 
failed other forms of airway clearance therapy. Individual consideration should be based on the enrollee's 
needs. The Plan denied your request. The Plan says there is no data to support that this device using IPV is 
effective and is not covered for use in the home 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same 
purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.   
We looked at the file and Medicare rules. The records show that the enrollee already has a chest wall oscillating device. Medicare guidelines state "Additional expenses for "deluxe" features, or items that are 
rented or purchased for aesthetic reasons or added convenience, do not meet the reasonableness test. You can 
find this information in Medicare Claims Processing Manual Chapter 20 - Durable Medical Equipment, 
Prosthetics, Orthotics, and Supplies (DMEPOS), Section 90 - Payment for Additional Expenses for Deluxe 
Features.  Based on this information, we decided that Medicare rules for coverage of the Volara device have 
not been met. Therefore, we decided that the Plan does not have to pre-approve the Volara high frequency 
chest wall oscillation device (E1399).
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 need IRF care to do frequent dialysis and get 
appropriate care. The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF 
services do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 Our physician reviewer found that you are medically stable and do not need physical medicine and 
rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical conditions. While you may benefit from physical therapy and 
occupational therapy at your current functional level, you do not need intensive therapies, consisting of at least 
3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. 
Your rehabilitation can be safely provided at a lower intensity and alternate setting. An IRF admission is not 
medically necessary based on medical stability and lack of medical complexity and lack of acute rehabilitation 
nursing needs. Your rehabilitation needs can be met at a lower intensity setting. The documentation does not 
support the necessity for admission to 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PureWick system. 
 
You asked the Plan to pre-approve the requested device. You say that the enrollee only needs 1 per night. The 
Plan denied your request. The Plan says this device would be more costly than alternative pieces of equipment. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The file shows that the requested device was requested to get a better 
nights rest. The device is being requested for a use that is not primarily medical in nature. Based on this 
information, we decided that Medicare rules for coverage of the requested device have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a PureWick system.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ajovy. 
 
You asked the Plan to pre-approve Ajovy. The Plan denied your request. The Plan says a subcutaneous 
injection (a shot under the skin) that can be self-administered is covered by the pharmacy (drug) 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 Ajovy.  
 
  Benefits for Ajovy 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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM), Freestyle Libre 14-
day sensor (95249). 
 
You asked the Plan to pay for the Freestyle Libre 14-day sensor. You say that the enrollee has monocular 
vision, which makes it difficult to check his glucose levels using a standard glucose monitoring system. The 
Plan denied your request. The Plan says the records do not support that the enrollee meets all of the coverage 
criteria for the requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan.  
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the Freestyle Libre 14-day sensor have not been 
met. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM), 
Freestyle Libre 14-day sensor (95249).
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 the enrollee needs IRF care. The Plan denied your 
request. The Plan says under Medicare, the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found that the enrollee is medically stable does not need physical medicine and 
rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical conditions. While the enrollee may benefit from physical 
therapy and occupational therapy, at the current functional level, the enrollee does not need intensive therapies, 
consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to 
daily therapy in an IRF. The enrollee's rehabilitation can be safely provided at a lower intensity and alternate 
setting. An IRF admission is not medically necessary based on medical stability and lack of medical 
complexity and lack of acute rehabilitation nursing needs and high functional level. The enrollee's 
rehabilitation needs can be met at a lower intensity setting. The documentation does not support the necessity 
for admission to 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.