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

 
We decided that the Plan has to pay for the in-home care provided from April 27, 2020, to May 30, 2020. 
 
You asked the Plan to pay for the in-home care. You say that the enrollee was forced to hire caregivers for 
home care because no rehabilitation centers would admit him due to COVID-19. The Plan denied your request. 
The Plan says that this service is not a benefit under the enrollee's plan. The Plan also says that the records do 
not show evidence of receipt of prior authorization or certification of home health services. 
 
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 did not provide a copy of the applicable medical records for this case. 
Without this information we cannot determine that the Plan's coverage rules support the denial of payment in 
this case. Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we 
decided that the Plan has to pay for the in-home care provided from April 27, 2020, to May 30, 2020.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT, orbit, sella, or posterior fossa or outer, middle, or 
inner ear; without contrast material (CPT code 70480) provided on November 23, 2021. 
 
You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not covered as billed.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70480 
is a column II code to column I code 70450. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the CT, orbit, sella, or posterior fossa or outer, middle, or inner 
ear; without contrast material (CPT code 70480) provided on November 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the allergy immunotherapy (95165), provided on September 
7, 2021. 
 
You asked the Plan to pay for the allergy immunotherapy. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that 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 pay for the allergy immunotherapy. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the patient has been receiving 
doses ranging from every other day to two times per week after being on immunotherapy for 4 years (she is in 
her 5th year of allergy shots). This is outside the typical dosing for buildup and maintenance phases according 
to current guidelines. 
 
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 allergy immunotherapy have not been met. Therefore, we decided that the 
Plan does not have to pay for the allergy immunotherapy (95165), provided on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Ambulatory Blood Pressure Monitoring, provided on 
December 9, 2021. 
 
You asked the Plan to pay for the Ambulatory Blood Pressure Monitoring. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that ABPM is reasonable and necessary for the diagnosis 
of hypertension in Medicare beneficiaries under the circumstances listed 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 pay for the Ambulatory Blood Pressure Monitoring. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the information 
provided shows the enrollee does not have masked blood pressure issues nor white coat syndrome. 
 
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 Ambulatory Blood Pressure Monitoring have not been met. Therefore, we 
decided that the Plan does not have to pay for the Ambulatory Blood Pressure Monitoring, provided on 
December 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 LTACH services. You say that LTACH services are medically necessary. 
The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient care at the current 
hospital and the LTACH would offer no additional services. 
 
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. Our 
physician reviewer found that all medically necessary care is being provided in the current acute care facility. 
 
 
 
 
 
 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 over-the-counter COVID-19 home test kit purchased January 
8, 2022. 
 
You asked the Plan to pay for the home test kit. You say that you were told by the Plan that the test was 
covered. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the home 
test kit is an OTC item. Therefore, we decided that the Plan does not have to pay for over-the-counter COVID-
19 home test kit purchased January 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya (J3254). 
 
You asked the Plan to pre-approve Ilumya. You say that this should be covered. The Plan denied your request. 
The Plan says Ilumya is a self-administered drug. The Plan says that coverage is only available for coverage 
under the enrollees Medicare Part D 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 Ilumya (J3254).  
 
Benefits for Ilumya 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need additional 
transportation rides for your upcoming appointments. The Plan denied your request. The Plan says additional 
trips would exceed your benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. The records show that you have used 
nineteen (19) one-way transportation trips out of the allowed twenty-four (24) one-way trips approved. Once 
24 trips are used, the benefit will be exhausted. Based on this information, we decided that the Plans rules for 
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve additional routine transportation trips (A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a peripheral nerve stimulator (64555, 76942). 
 
You asked the Plan to pre-approve a peripheral nerve stimulator. You say that the service is medically 
necessary. The Plan denied your request. The Plan says this is not a covered benefit by Medicare for the 
member's condition. 
 
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 a peripheral nerve stimulator. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found this therapy would be experimental/ investigational for treatment of the pain 
from osteoarthritis of the knee. 
 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 peripheral nerve stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a peripheral nerve stimulator (64555, 76942).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for hearing aid services provided to the enrollee on October 19, 2021. 
 
You asked the Plan to pay for the services. You say that you do not see any errors with this claim. The Plan 
denied your request. The Plan says that this service is not considered appropriate for this diagnosis. 
 
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 stated why the billed diagnosis is inappropriate for these 
services. They have not specified how to correct this billed claim. Therefore, we decided that the Plan has to 
pay for hearing aid services provided to the enrollee on October 19, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rhythm electrocardiogram (93042, 99285) provided to the 
enrollee on July 5, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is no clinical documentation indicating any signs or symptoms or systemic conditions that 
substantiate the need for these services provided. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found no medical records have been provided in this case to document that the enrollee had a condition for 
which this rhythm electrocardiogram (93042, 99285) would have been appropriate. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for a rhythm electrocardiogram (93042, 99285) provided to the enrollee on July 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Ability Drive control for the enrollee's power 
wheelchair. 
 
You asked the Plan to pre-approve the requested device. You say that the Ability Drive is the most clinically 
effective option available. The Plan denied your request. The Plan says experimental items are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that wheelchair items and accessories are only 
covered under certain medical indications. 
 
 
 We looked at the file and Medicare rules. The case file does not show that the requested device is not covered 
by Medicare. 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 an Ability Drive control 
for the enrollee's power wheelchair.
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  LTACH services. You say that LTACH services are medically necessary 
for the enrollee to regain maximum function. The Plan denied your request. The Plan says the enrollee is 
receiving appropriate inpatient care at the current hospital and the LTACH would offer no additional services. 
 
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. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not already 
available at the current facility. 
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiologic examination, elbow provided on July 7, 2021. 
 
You asked the Plan to pay for the radiologic examination, elbow. The Plan denied your request. The Plan says 
per CMS guidelines Original Medicare Fee for Service retains payment responsibility for all hospice and non-
hospice related claims, except for Part D services and supplemental services, from the date of the hospice 
election through the end of the month of the hospice revocation/election termination. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a radiologic examination, elbow provided on July 7, 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. You say that the enrollee meets the IRF admission criteria under 
CMS guidelines. You say that the enrollee is stable and suitable for transfer to an IRF. You say that skilled 
nursing is not an appropriate safe level of are at this time as the enrollee will need more frequent physician 
visits and frequent monitoring and interventions. You say that the enrollee will need more nursing care that the 
typical amount supplied in a skilled nursing facility. You say that the enrollee requires aggressive therapy and 
close physician monitoring. The Plan denied your request. The Plan says the guidelines for coverage of IRF 
care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the 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 infection at site of surgical amputation of a toe and had a below the knee amputation. The 
enrollee's 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, and 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. There is not a reasonable 
expectation that this enrollee 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3D rendering for a mammogram. 
 
You asked the Plan to pre-approve these 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. 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 services are not medically necessary. Our physician reviewer found yo underwent a 2D full-field digital 
mammogram on March 15, 2021. The breasts were noted to be extremely dense, which lowers sensitivity to 
mammography. There is no significant interval change and no evidence of malignancy. An annual screening 
mammogram was recommended. The records do not support that 3D rendering for the screening mammogram 
is reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 3D rendering for a mammogram.
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 requested admission to an IRF does not meet 
criteria. 
 
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 you are medically stable and do not need PM&R physician supervision 3 times per 
week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. At the current functional level which is same as baseline level with therapy (see therapy notes), 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 in an IRF. Your rehab needs can be met safely and provided at a lower intensity and 
alternate setting such as in a skilled nursing facility with intermittent therapies. 
 
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.