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

 
We decided that the Plan does not have to pre-approve Enhertu. 
 
You asked the Plan to pre-approve Enhertu. The Plan denied your request. The Plan says there is no support for 
Enhertu for the enrollee's condition. 
 
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. In this case, medical records were not provided to show that the 
requested drug is necessary. The Plan made multiple attempts to obtain additional information without success. 
Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Enhertu.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary. The Plan 
denied your request. The Plan says that this is not covered for your condition. 
 
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 a portable ventilator. Our reviewer says 
that a portable ventilator is not medically reasonable and necessary. You have COPD, but chronic CO2 
retention has not been established with an arterial blood gas done while you are stable as an outpatient. The 
PCO2 of 66 is from a venous blood sample. If you have chronic CO2 retention, you may benefit from BiPAP 
during sleep using the average volume-assured pressure support mode. Medicare does not cover a home 
ventilator when used as BiPAP.  Our physician reviewer found that your condition does not meet Medicare criteria for a portable ventilator. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a subcutaneous cardiac rhythm monitor. 
 
You asked the Plan to pre-approve insertion of a subcutaneous cardiac rhythm monitor. You say that the 
services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria 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 insertion of a subcutaneous cardiac 
rhythm monitor. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found imaging has shown left carotid artery stenosis, treated 
with medication. The enrollees echocardiogram showed no significant ventricular dysfunction. Office 
electrocardiogram (ECGs) and a 24-hour Holter monitor have shown no atrial fibrillation. In summary, there is 
insufficient documentation to support the medical necessity for insertion of an implantable loop recorder (ILR) 
in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of a subcutaneous cardiac rhythm monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of a subcutaneous cardiac rhythm 
monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from May 27, 2021, to June 
1, 2021, as billed with Diagnosis Related Group (DRG) 377. 
 
You asked the Plan to pay for inpatient care as billed with DRG 377. You say that these services were 
medically necessary and are supported in the record. The Plan denied your request. The Plan says The Plan argues that DRG 377 is not supported as the secondary diagnosis of acute respiratory failure with hypoxia 
(J96.01) is not supported in the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. 
 
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 inpatient care as billed with DRG 377. Our 
reviewer says that the secondary diagnosis of acute respiratory failure with hypoxia (J96.01) is not supported in 
the medical record. Our physician reviewer found that the emergency department documentation stated that the 
enrollee denied respiratory signs in the review of symptoms, and the lung sounds were clear and non-labored to 
auscultate. The history and physical stated a physical exam reflecting diminished breath sounds, however 
pulmonary effort was described as non-labored, no accessory muscles were being used, the enrollee was able to 
speak in complete sentences, and once the enrollee was placed on home oxygen the saturation levels were 
greater than 93%. The enrollee was noted to have orders for 3 liters oxygen at baseline to be used, which would 
be expected to reflect the enrollee to have saturations greater than 90% at baseline, and while the "pO2 of 45" 
was acknowledged to be present, the arterial blood gas done on room air would be unclear in baseline in the 
setting of chronic necessary oxygen use "when needed" and notations of stable respiratory effort in the setting 
of severe anemia. It is unclear that the enrollees saturation levels were beyond what was baseline in the setting 
of documented chronic respiratory failure as noted in the progress note and only "hypoxemia" noted in the 
discharge summary with notations that the enrollee wears oxygen as needed and at discharge was 92% on room 
air. The review has determined that the medical records did not support the billing of secondary diagnosis acute 
respiratory failure with hypoxia (J96.01). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care as billed with DRG 377 have not been met. Therefore, we 
decided that the Plan does not have to pay for inpatient hospital care provided from May 27, 2021, to June 1, 
2021, as billed with Diagnosis Related Group (DRG) 377.
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 disagree with the denial. The Plan denied your 
request. The Plan says the services are 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 medically necessary. Our physician reviewer found you were admitted to the hospital 
for aneurysm repair and had prolonged post-operative respiratory failure. You are now medically stable with no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a 
need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided from August 5, 2021, 
through September 29, 2021. 
 
You asked the Plan to pay for psychotherapy services. You say that you were not aware that providers had to 
opt-in to Medicare to be covered. The Plan denied your request. The Plan says for services to be covered, the 
providers must participate with Original Medicare whether they are in network or out of network to receive 
payment from the Plan. 
 
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 
psychotherapy services provided from August 5, 2021, through September 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that your medical needs are being met in the current acute setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. You do not 
require services at the LTACH that are not available at the acute care hospital where you are currently 
receiving care. All medically necessary care is being provided in the current acute care facility. There are no 
services available at the LTACH that you require that are not available at the health care setting being offered 
by the health plan. Our physician reviewer found that your condition does not meet Medicare criteria for 
LTACH 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychological and neuropsychological testing. 
 
You asked the Plan to pre-approve psychological and neuropsychological testing. The Plan denied your 
request. The Plan says psychological and neuropsychological testing does not meet the Medicare LCD 
coverage criteria and is not medically necessary. 
 
The Plan follows Medicare rules.  
 
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 psychological and neuropsychological 
testing. Our reviewer says that psychological and neuropsychological testing is not medically necessary. Our 
physician reviewer found that based on review of the records provided, it was noted that this enrollees 
provider wanted to rule out Alzheimer's Dementia however the enrollee had a Montreal Cognitive Assessment 
(MoCA) evaluation in March of 2022 that was showing Mild Cognitive Impairment. Based on review the 
records provided in the information provided this enrollee does not meet the criteria for additional 
neuropsychological testing beyond which is approved by LCD 33632 based on the enrollees clinical record. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of psychological and neuropsychological testing have not been met. Therefore, we 
decided that the Plan does not have to pre-approve psychological and neuropsychological testing (CPT 99132).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not medically necessary. Our physician reviewer found the enrollee does not 
require services at the LTACH that are not available at the acute care hospital where he is currently receiving 
care. All medically necessary care is being provided in the current acute care facility. There are no services 
available at the LTACH that the enrollee requires that are not available at the health care setting being offered 
by the health plan. The health plan has approved ongoing care in the current acute care facility. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on September 1, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code.  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 the genetic testing services provided on September 
1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 19, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
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 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on September 27, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the service were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. 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 the genetic testing services provided on September 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-ray services provided on June 1, 2021. 
 
You asked the Plan to waive the copayment for x-ray services. The Plan denied your request. The Plan says the 
claim paid with the correct copayment. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $45 copayment for outpatient diagnostic tests and therapeutic services and supplies, Specialist's 
Office.  
 
The enrollee has been asked to pay a $45 copayment for x-ray services. The x-ray services falls within the 
outpatient diagnostic tests and therapeutic services and supplies, Specialist's Office benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost 
sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided 
that the Plan does not have to waive the copayment for x-ray services provided on June 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision services (92014, 92015, 92250) provided on July 12, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for OON vision care. You say that you were not aware that the provider was not 
contracted with the Plan and required authorization. The Plan denied your request. The Plan says out-of-
network care is only covered in certain limited circumstances. The services at issue were not urgent or 
emergent, nor were they pre-approved. 
 
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 vision services (92014, 92015, 92250) provided on 
July 12, 2021, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, emergency 
transport (A0429) and ground mileage (A0425) provided on August 30, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the services should be covered. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on August 29, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the ambulance 
service, basic life support, emergency transport (A0429) and ground mileage (A0425) provided on August 30, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided September 22, 
2021. 
 
You asked the Plan to pay for the orthosis. You say that the notes show the ordering doctor prescribed the back 
brace to facilitate pain by restriction of the trunk to help the enrollee's quality of life. The Plan denied your 
request. The Plan says the records do not support the billed service 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the lumbar-sacral orthosis (L0650) 
provided September 22, 2021. have been met. Complete treatment records were not received, did not include a 
start/stop time for the visit and was insufficient and did not support that the provider rendered the services to 
the enrollee. The records also show that the enrollee stated she has never heard of the provider and has never 
needed or used any type of braces. Therefore, we decided that the Plan does not have to pay for the lumbar-
sacral orthosis (L0650) provided September 22, 2021.