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

 
We decided that the Plan does not have to waive the cost sharing amount for the chemotherapy infusion 
services provided from May 27, 2021, to October 27, 2021 
 
You asked the Plan to waive the cost sharing amount for the chemotherapy services. You say that you were 
told that these services were covered. You also say that your doctor was advised the services were approved. 
The Plan denied your request. The Plan says there is a 20% copayment of the cost of drugs that are injected or 
infused while you are getting physician, hospital outpatient, or ambulatory surgical center services. This is 
different than the co-pay you are accustomed to paying for the office visit. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
copayment for Medicare Part B prescription drugs.  
 You have been asked to pay 20% copayment for the chemotherapy services. The chemotherapy services fall 
within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost sharing 
amount for the chemotherapy infusion services provided from May 27, 2021, to October 27, 2021
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the enrollee has been receiving these injections since 
2021. The Plan denied your request. The Plan says the provided documentation does not indicate that the 
enrollee has a qualifying diagnosis. 
 
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 Prolia. Our reviewer says that the 
requested drug, Prolia, is not medically necessary. Our physician reviewer found the Food and Drug 
Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare 
approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's 
clinical situation. Therefore, the reviewer found that the requested drug is not 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pontic (D6245) and two retainer crowns (D6740 x2) 
provided on September 1, 2021. 
 
You asked the Plan to pay for the pontic and retainer crowns. You say that you would like to appeal these 
services. The Plan denied your request. The Plan says these services are not covered expenses 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 Plans 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 pontic 
(D6245) and two retainer crowns (D6740 x2) provided on September 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT code 99051 billed on November 21, 2021. 
 
You asked the Plan to pay for CPT code 99051. You say that CPT code 99051 denied as procedure is not paid 
separately. You say that medical records along with progress notes are attached to reprocess the denied claim. 
The Plan denied your request. The Plan says bundled services are not eligible for separate payment. 
  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 99051 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99051 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of CPT code 99051 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 
99051 billed on November 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for endoscopic procedures (00731) provided on 
December 17, 2021. 
 
You asked the Plan to pay for anesthesia for endoscopic procedures (00731). You say that the claim should be 
reconsidered with the attached documents and reprocessed for payment. The Plan denied your request. The 
Plan says outpatient Place of Service was billed while the enrollee was an inpatient. 
 
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 00731 is anesthesia for upper gastrointestinal endoscopic 
procedures, endoscope introduced proximal to duodenum; not otherwise specified. 
 
We find that CPT code 00731 is not supported in the medical record. Specifically, the outpatient Place of 
Service code was billed while the enrollee was an inpatient. Based on this information, we decided that 
Medicare rules for coverage of anesthesia for endoscopic procedures (00731) have not been met. Therefore, we 
decided that the Plan does not have to pay for anesthesia for endoscopic procedures (00731) provided on 
December 17, 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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the member does not have acutely complex medical diagnosis and does 
not require supervision by a rehabilitation physician. 
 
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. The 
enrollee is medically stable and has no medical complexity and does not need physical medicine and 
rehabilitation physician close supervision 3 times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical conditions. There are no rehab nursing needs identified or 
documented in the record. At the current functional status, the enrollee does not need 3 hours a day five days a 
week of IRF therapies with interdisciplinary management. The enrollee needs physical and occupational 
therapy, and they can be provided in a lower intensity setting. She is stable with no medical complexity. The 
complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
rehab stay with an interdisciplinary approach to rehabilitation care. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for IRF care. 
 
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 for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on November 23, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you feel 
this service should be covered in full. The Plan denied your request. The Plan says you refused transportation 
per the records provided. The Plan also says that you were evaluated and were informed what should happen if 
you did not begin to feel better. 
 
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 November 23, 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 the ambulance response and treatment with no 
transport (A0998) provided on November 23, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray provided on December 17, 2021. 
 
You asked the Plan to pay for the x-ray. You say that the enrollee was not enrolled in hospice on the date of 
service in this case. 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 December 6, 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 chest x-ray 
provided on December 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on June 15, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you did 
not want to go to the hospital because of COVID-19 or because of a low blood sugar. You also say that you 
were not advised that if you did not go to the hospital the service would not be covered. The Plan denied your 
request. The Plan says the Plan says that you declined transportation to the emergency room for an evaluation. 
 
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 June 15, 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 the ambulance response and treatment with no 
transport (A0998) provided on June 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable home ventilator for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request for a home mechanical ventilator with settings that could be delivered by 
bilateral positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) for this 
enrollee with chronic obstructive pulmonary disease (COPD) is not covered. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the Life2000 System is not medically necessary.  This system provides positive pressure oxygen in a 
portable device, but is not a true ventilator. The evidence supporting efficacy and safety of this device, in the treatment of any lung disease, is inadequate. This patient has interstitial lung disease and obstructive sleep 
apnea. There is emphysema on computed tomography (CT) scan, but there is no airways obstruction on 
spirometry, and FEV1 is normal. There is no indication for a ventilatory assist device, other than the 
continuous positive airway pressure (CPAP).  
 
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 pre-approve a portable home ventilator for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive 
interface (e.g., mask, chest shell) (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you have a lung problem and have trouble 
breathing. Your condition is life threatening and would put you at a heightened risk of serious harm or 
morbidity if you do not use a non-invasive ventilator. The Plan denied your request. The Plan says the records 
provided do not support that the Medicare criteria has been met. 
 
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 the requested items/services are not considered medically reasonable and necessary in this case.  Our physician reviewer found a home ventilator is not medically necessary. This enrollee has COPD, although 
no pulmonary function tests are provided.  The enrollee had a PaCO2 of 62.6 when acutely ill in 2021, but 
there is no arterial blood gas when stable as outpatient to confirm chronic CO2 retention. The enrollee has 
standard bilevel positive airway pressure (BiPap) at home, but there is no data download to confirm use. 
Settings are not provided. The enrollee reports mask leak problems, but these have apparently not been 
addressed. BiPap with average volume assured pressure support has not been tried. Medicare does not pay for a 
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, any type, used with non-invasive interface (e.g., mask, chest shell) 
(E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dentures. 
 
You asked the Plan to pre-approve dentures. You say that the dentures the enrollee received in 2019 have 
broken and they are no longer usable. The Plan denied your request. The Plan says the benefit for dentures is 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, coverage for dentures is limited to 1 
pair every 5 years. The records show that the enrollee received coverage for dentures provided in 2019. This 
means that the benefit for coverage of dentures is currently exhausted. Therefore, we decided that the Plan does 
not have to pre-approve dentures.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the sacral wound is healed, there are no longer complaints of pain, and there is no 
documentation of present wound care needs. 
 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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the enrollee does 
not have documented skilled nursing needs (i.e. IVs, complex wound care, new tube feeds, new ostomy, etc). 
As such, the requested home health skilled nursing services are not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pain management services provided to the enrollee on 
December 6, 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 the records provided to the plan are unsigned and undated. 
 
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 pain management services provided to 
the enrollee on December 6, 2021 have been met. The provider has not sent int appropriate medical records in this case. The records must be signed and dated to verify the services.. Therefore, we decided that the Plan does 
not have to pay for pain management services provided to the enrollee on December 6, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 home test kit (87811) provided on January 
20, 2022. 
 
You asked the Plan to pay for the COVID-19 home test kit. You say that you were under the impression that 
the Plan would cover 8 free over the counter COVID-19 home test kits. The Plan denied your request. The Plan 
says this test kit is not covered under the terms of your policy. The Plan also says that the test kits can be 
ordered and covered through the federal government. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare will only pay for claims with dates of 
service starting on or after April 4, 2022, through the last day of the COVID-19 public health emergency 
(PHE), and claims should be submitted to Original Medicare for patients enrolled in a Medicare Advantage 
(MA) plan.  
 
We looked at the file and Medicare rules. Over the counter (OTC)/at-home COVID-19 tests began on April 4, 
2022, which means that tests for dates of service April 4, 2022 and after are paid for. OTC tests before that date 
are only covered if the Plan has a supplemental benefit for them, which this plan does not seem to have. 
Centers for Medicare & Medicaid Services (CMS) instructs that for a Medicare Advantage beneficiary, the 
claim for the test should be submitted to Original Medicare instead of the Plan. Even though they are covered 
for beneficiaries enrolled in a Part C plan, the Plan does not have to pay it themselves. Based on this 
information, we decided that Medicare rules for coverage of the COVID-19 home test kit have not been met. Therefore, we decided that the Plan does not have to pay for the COVID-19 home test kit (87811) provided on 
January 20, 2022.  
 
Please Note: You could try to request reimbursement from Medicare itself for the at home COVID-19 test.
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 does 
not meet criteria. 
 
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 you appear to be unstable and require additional short-term acute care services that 
can safely be administered at the current facility until more stable for transfer. It is not yet clear if you are 
weanable at this time. There are no services at the LTACH that you require that are not already available and 
covered at the current facility. Transfer to LTACH is not medically necessary as you are not stable enough for 
transfer yet, and as it would not be clinically advantageous. 
 
 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.