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

We decided that the Plan does not have to pay for the laboratory services provided on July 9, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The laboratory services at issue in this appeal were requested solely for screening purposes. Medicare does not
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the
laboratory services provided on July 9, 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 the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is 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 admission to a LTACH is not medically necessary. Our physician reviewer found based on
the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for
CoViD-19. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services
that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is
no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for
any ongoing long term care 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 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the information submitted doesn't meet the plan's medical necessity guidelines for coverage.
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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee is noted to have right knee osteoarthritis. A request has been made for Gel-One, a hyaluronic acid injection, to treat the osteoarthritis. The health plan requires that other forms of hyaluronic acid be used. There is no evidence that the enrollee is allergic to or intolerant of these other forms of medication. There is no evidence that the enrollee has tried and not responded to these other forms of medication. There is no documentation as to why these other forms of medication would not be expected to be safe and effective for the enrollee. Therefore, the requested Gel-One is not shown to be currently medically necessary and reasonable. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One for the enrollee
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services performed by a qualified occupational therapist
(G0152), direct skilled nursing services of a registered nurse (RN) (G0299), and home health care provided in
patient's home/residence (Q5001) provided from May 14, 2021, to May 18, 2021.
You asked the Plan to pay for the services performed by a qualified occupational therapist, direct skilled
nursing services of a RN, and home health care provided in patient's home/residence. You say that this claim
was billed correctly per Medicare guidelines and should be reprocessed for payment. The Plan denied your
request. The Plan says the initial Request for Anticipated Payments (RAP) claim was not received within 5
calendar days from the start of care.
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day
periods and within 5 calendar days after the "from date" for each subsequent 30-day period of care, which is set
at 0 percent at the beginning of every 30-day period.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the services performed by a qualified occupational therapist, direct skilled nursing services of a
RN, and home health care provided in patient's home/residence have not been met. Specifically, the record
indicates the RAP was not submitted within 5 days of the from the start of care date, May 14, 2021. Therefore,
we decided that the Plan does not have to pay for the services performed by a qualified occupational therapist
(G0152), direct skilled nursing services of a registered nurse (RN) (G0299), and home health care provided in
patient's home/residence (Q5001) provided from May 14, 2021, to May 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on July 27, 2021 by an out-of-
network (OON) provider.
You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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 genetic testing provided on July 27, 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 Microlet lancets for the enrollee.
You asked the Plan to pre-approve the lancets. You say that this is medically necessary. The Plan denied your
request. The Plan says there has been no trial and failure with the preferred brand
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 lancets. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found there is no evidence as to why the requested brand 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 the lancets have not been met. Therefore, we decided that the Plan does not
have to pre-approve Microlet lancets for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on February 9, 2021.
You asked the Plan to pay for the services provided. You say that the tests were billed as ordered by the
physician. The Plan denied your request. The Plan says the billed code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.
We looked at the file and the rules. The claim provided lists a place of service as an independent laboratory.
The records do not indicate the specimen was obtained at an independent laboratory. Based on this information,
we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided
that the Plan does not have to pay for the drug testing services provided on February 9, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for a rhythm electrocardiogram (ECG) report provided on February 3, 2021.
You asked the Plan to pay for rhythm ECG report. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 93042 is included in code 93010 and is not separately payable.
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Specifically, the record does not show that the rhythm electrocardiogram was a distinct procedural service from electrocardiogram report (code 93010) to which it is inclusive. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for a rhythm electrocardiogram (ECG) report provided on February 3, 2021
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998)
provided on April 25, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request.
The Plan says because the member was not actually transported by ambulance, this expense is not covered by
the member's Plan.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on April 25, 2021. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport
(A0998) provided on April 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital care services provided on April 27, 2021.
You asked the Plan to pay for the services provided. You say that the medical records support the code. The
Plan denied your request. The Plan says the service is included in the payment for another service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
The file shows that CPT code 99221 was billed on the same date of service as CPT code 99223. We find that
CPT code 99221 is not eligible for payment when billed with this code pair. Based on this information, we
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided
that the Plan does not have to pay for the hospital care services provided on April 27, 2021.
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. The Plan denied your request. The Plan says the IRF admission 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 the provided documentation does not indicate that you have complex nursing or
rehabilitation needs. The reviewer found that while you have a need for physical and/or occupational therapy,
there is no documentation of a need for an intensive rehabilitation program. The reviewer also found that 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. Specifically, the file does not indicate that you
have complex nursing or rehabilitation needs. 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 portable ventilator.
You asked the Plan to pre-approve a portable ventilator. You say that the requested device was specifically
prescribed to help manage the enrollee's respiratory needs at home. You say that the requested device is
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria for
coverage.
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 the criteria for coverage have not been met. Our physician reviewer found the Life2000 System is not
medically necessary. This system is not a true ventilator, because it does not have the capability of providing
full ventilatory support.
It delivers positive pressure oxygen via nasal canula and is intended to be used during activity. There is
inadequate evidence that this device is beneficial in chronic obstructive pulmonary disease, or any other
pulmonary diagnosis.
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: 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 requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an
interdisciplinary approach to rehabilitation care. The enrollee was admitted for thoracic spinal surgery.
Medical problems are stable. There are no complex nursing or rehabilitation needs.
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or
occupational therapy, there is no documentation of a need for an intensive rehabilitation 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and abutment
supported porcelain fused to metal crown (D6061) provided on September 20, 2021.
You asked the Plan to pay for the custom fabricated abutment and abutment supported crown. You say that you
understood that the crowns were covered per the website information. You also say that the information did not
indicate that crowns related to implants would not be covered. The Plan denied your request. The Plan says
these services are not covered benefits under your dental plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's 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 pay for the
custom fabricated abutment (D6057) and abutment supported porcelain fused to metal crown (D6061) provided
on September 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.
You asked the Plan to pre-approve a home ventilator. You say that the enrollee requires augmented ventilation,
which is a setting that is not found in bi-level positive airway pressure (BiPAP). You say that noninvasive
ventilation would be extremely beneficial in improving the enrollee's ability to recover muscle de-conditioning
and will dramatically improve quality of life. You say that, without noninvasive ventilation, the enrollee's
condition will condition to deteriorate and lead to exacerbation. The Plan denied your request. The Plan says
the enrollee does not meet the criteria for coverage of the requested breathing machine.
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 home ventilator.
Our reviewer says that a home ventilator is not medically necessary Our physician reviewer found the enrollee
has severe obstructive lung disease, obstructive sleep apnea, and possible obesity hypoventilation syndrome
that is aggravated by narcotics for chronic pain. Carbon dioxide retention is documented. A recent sleep study
with positive airway pressure titration reportedly indicated persistent hypoventilation on bilevel positive airway
pressure (BiPAP.) It appears the enrollee could benefit from more aggressive nocturnal ventilatory support.
However, certain BiPAP devices are capable of providing the average volume-assured pressure support
(AVAPS) mode of support that has been ordered, at less cost to the enrollee. Medicare does not cover a home
ventilator when 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 a home ventilator have not been met. Therefore, we decided that the Plan does
not have to pre-approve a home ventilator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the hernia repair (49561) provided on April 14, 2021.
You asked the Plan to pay for the hernia repair (49561). You say that procedure code 49561 was distinct and separate and should be paid. The Plan denied your request. The Plan says procedure code 49561 would be considered inclusive to procedure code 44120.
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 49561 is repair initial incisional or ventral hernia; incarcerated or strangulated.
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 hernia repair (49561). Our reviewer says that this does not meet the criteria for reimbursement consideration for 49561 as a distinct, separate service. Our reviewer found that CPT code 49561-AS-59 is considered inclusive to 44120-AS-59. The records provided state, if a hernia repair is performed at the site of an incision for an open or laparoscopic abdominal procedure, the hernia repair is inherently inclusive, and not separately reported. 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 hernia repair (49561) have not been met. Therefore, we decided that the Plan does not have to pay for the hernia repair (49561) provided on April 14, 2021.