Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four additional home health skilled nursing visits for the 
enrollee. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says the records do not support the need for a skilled nurse to make more visits. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional visits. Our reviewer says 
that the requested additional visits are not medically reasonable or necessary. Our physician reviewer found 
that the records provided are for a recertification visit on June 29. The visit was recorded as visit 11; the 
original date that service began is not evident in the record. The enrollee has a number of chronic issues 
including depression, cognitive loss, chronic lung disease, and reduced function. His medication regimen is 
stable and his medical condition is stable with some chronic symptoms - shortness of breath, a sad mood, 
incontinence. The enrollee has an established and effective maintenance program. No adjustment with 
continued observation is indicated, per the records. There is no evidence that the enrollee's condition will 
improve beyond his current state. The enrollee's condition is stable with an effective maintenance program and 
no indication for an intervention or plan to improve his chronic state. 
 
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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve four additional home health skilled nursing visits for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services coded 99100 provided on May 17, 
2021. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not separately payable. 
 
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 99100 is not supported in the medical record. Specifically, this code has a status 
indicator of "B". This means that payment for this service is always bundled into payment for other services not 
specified. No separate payment can be made. Based on this information, we decided that Medicare rules for 
coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay 
for the anesthesia services coded 99100 provided on May 17, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two home health skilled nursing visits. 
 
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not support the need for a skilled nurse to make more visits. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 visits. Our reviewer says that the 
requested additional visits are not medically reasonable or necessary. Our physician reviewer found that the 
wound has healed after 25 visits. A stable and effective maintenance program is in place to work on restoring 
ambulation. There are no medication changes, changes in condition, except that the wound has healed. There is 
no indication for any skilled nursing intervention to improve the enrollee's condition. 
 
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 visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve two home health skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rest home visit provided on November 4, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the rest home visit. You say that the enrollee was bound to the facility and the 
service was deemed necessary. The Plan denied your request. The Plan says no prior authorization was 
obtained. 
 
 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 did not pre-approve the 
rest home visit. We found no exception that would require the Plan to pay for the rest home visit. The records 
provided for review do not show that the rest home visit was urgent or emergent. Therefore, we decided that 
the Plan does not have to pay for the rest home visit provided on November 4, 2021, by an out-of-network 
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 31, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
 
 
 
 
 
 We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on October 31, 2021.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to waive the copayment for ER visit provided on February 4, 2022 
 
You asked the Plan to waive the copayment for ER visit. You say that you shouldn't have to pay a copayment. 
The Plan denied your request. The Plan says that the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay $0 copayment for Emergency Care.  
 
The Plan says you must pay $120 copayment for ER visit. Based on the Plan contract, however, you cannot be 
asked to pay more than $0 copayment for ER visit. Therefore, we decided that the Plan has to waive the 
copayment for ER visit provided on February 4, 2022  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory work provided on March 1, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory work. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
laboratory work. We found no exception that would require the Plan to pay for the laboratory work. The record 
shows CPT code 36415 was billed which means the provider had the opportunity to confirm insurance 
coverage and authorization. Therefore, we decided that the Plan does not have to pay for the laboratory work 
provided on March 1, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre 14 Day Sensor. 
 
You asked the Plan to pre-approve the sensor. You say that the enrollee takes Synjardy 12-5-1,000 mg twice a 
day. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
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 information sent in shows the enrollee does not need to change 
their insulin dose frequently based on their blood sugar test results. Based on this information, we decided that 
Medicare rules for coverage of the sensor have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Freestyle Libre 14 Day Sensor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device for the 
enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that indications for coverage are not 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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Current evidence 
based medical guidelines and peer reviewed literature do not fully support the spinal decompression device 
procedure over the gold standard of lumbar laminectomy. There is a lack of large volume, long-term peer-
reviewed outcome studies to support the use of this device for this enrollees medical condition. Our physician 
reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex Superion Interspinous device for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 15, 2021. 
 
You asked the Plan to pay for the services provided. You say that there is no agreement that the codes are 
included in the dialysis rate. The Plan denied your request. The Plan says the laboratory services are the 
responsibility of the dialysis center. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on December 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power wheelchair. 
 
You asked the Plan to pre-approve the power wheelchair. You say that you have no transportation and must 
walk for groceries and prescription medications. You state that heart attacks and asthma attacks happen while 
you are outside in extreme heat. The Plan denied your request. The Plan says a power wheelchair used for 
outside the home is not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve the power wheelchair.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four additional home health skilled nursing visits for the 
enrollee. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says the records do not support the need for a skilled nurse to make more visits. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional visits. Our reviewer says 
that the requested additional visits are not medically reasonable or necessary. Our physician reviewer found the 
enrollee has had eight sessions, which is a sufficient number to establish a maintenance program. The enrollee's 
chronic condition is stable. There are no improvement goals. The enrollee's condition does not require a 
continued skilled nursing intervention. 
 
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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve four additional home health skilled nursing visits for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment (DME) provided to the enrollee 
on November 23, 2021. 
 
You asked the Plan to pay for the services. You say that this should be reconsidered. The Plan denied your 
request. The Plan says a review of the enrollee's claim history and authorization show that the enrollee was in a 
skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
 
 
 
 
 
 
 Records show that the services were used in a SNF or hospital. Therefore, we decided that the Plan does not 
have to pay for durable medical equipment (DME) provided to the enrollee on November 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve TENS device, four or more leads, for multiple nerve 
stimulation (CPT code E0730). 
 
You asked the Plan to pre-approve the TENS. You say that it is a great way help your life and your pain, 
especially in your lower back in your sciatic nerve. The Plan denied your request. The Plan says the Medicare 
rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the TENS have not been met. The submitted clinical information 
indicates that you have a history of chronic low back pain. TENS therapy for CLBP will be denied as not 
reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve TENS device, four 
or more leads, for multiple nerve stimulation (CPT code E0730).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will clearly benefit from acute rehab to 
optimize her level of functioning prior to returning home. You say that a further delay in care will have a 
detrimental effect on the enrollee's ability to recover to the fullest extent. The Plan denied your request. The 
Plan says the requested 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 enrollee's medical status does not require intensive physician and nursing 
oversight in an IRF. While the enrollee may benefit from additional therapies, the documentation does not 
reveal that the enrollee's functional level requires this therapy on an intensive IRF level. 
 
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 IRF admission and services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Velcade. 
 
You asked the Plan to pre-approve Velcade. You say that you would like the Plan's denial of Velcade to be 
reconsidered for this enrollee, who is post-kidney transplant with antibody mediated rejection. The Plan denied 
your request. The Plan says that Velcade is not medically necessary. The Plan also says that this request does 
not meet FDA (Food and Drug Administration) approved indications and/or compendia supported indications 
for the enrollee's clinical presentation. 
 
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 Velcade. Our reviewer says that 
Velcade is reasonable and necessary. Our physician reviewer found although Velcade is not Food and Drug 
Administration (FDA) approved for the enrollee's diagnosis, there is some other data available that showed at 
24-month follow-up that treatment with Velcade was effected for antibody-mediated rejection (AMR). Our 
reviewer also found that the enrollee has limited options, and is at risk for losing their kidney. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Velcade have been met. Therefore, we decided that the Plan has to pre-approve 
Velcade.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0637) billed for date of service 
February 16, 2022. 
 
You asked the Plan to pay for a lumbar-sacral orthosis. You say that the item at issue was a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been 
met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order nor proof of delivery for the supplies provided in this case. 
The enrollee has indicated that the enrollee has not consulted a physician about a need for a lumbar-sacral 
orthosis. The enrollee also indicates that no lumbar-sacral orthosis has been provided. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided 
that the Plan does not have to pay for a lumbar-sacral orthosis (L0637) billed for date of service February 16, 
2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services rendered on August 2, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the -XU modifier is typically used to bypass column 1 column 2 code edits. 
 
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 states that the -XU modifier is used to bypass column 1, column 2 code 
edits; however, the documentation shows that the codes at issue were not billed with the -XU modifier. The 
Plan has not provided any documentation or Medicare rules to support that the services are not payable as 
billed. Therefore, we decided that the Plan has to pay for the laboratory services rendered on August 2, 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.