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

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this was needed due to a diagnosis of heart 
failure. The Plan denied your request. The Plan says this is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found that the 
enrollee does not have any parental medication, complex wound care or nutrition given via a feeding tube. The 
enrollee is medically stable without any acute exacerbations of chronic medical problems. The enrollee's 
physical function is at or near the baseline, and the enrollee can receive the services at a lower level of care. 
Admission to a SNF for inpatient skilled rehab services 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 the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for dental services and office visit on January 
26, 2022, to April 06, 2022. 
 
You asked the Plan to waive the cost sharing for dental services and office visit. You say that you want to 
appeal the amount being charged. The Plan denied your request. The Plan says the cost sharing you are being 
charged is correct. 
 
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 a 40% 
coinsurance for out-of-network Medicare-covered dental services. You must pay a $35 copayment per visit 
with a specialist. Covered services include consultation, diagnosis, and treatment by a specialist. For dental 
services the provider billed in the amount of $3,113 and the Plan paid $636.55. $3,113 - $636.55 = $2,476.45. 
$2,476.45 + $35 = $2,511.45. Therefore, results in the total cost sharing amount of $2,511.45.  
 You have been asked to pay a 40% coinsurance and a $35 copayment for dental services and office visit. 
Dental services and office visit falls within the Dental services and Physician/Practitioner services, including 
doctor's office visits 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 for dental services and 
office visit on January 26, 2022, to April 06, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a segmental pneumatic compressor to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a segmental pneumatic compressor. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the requested provider 
is out-of-network. The Plan also says that a segmental pneumatic compressor has been approved with a 
contracted durable medical equipment provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the item at issue and the segmental pneumatic compressor has been approved with a 
contracted durable medical equipment provider. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a segmental 
pneumatic compressor to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair with accessories. 
 
You asked the Plan to pre-approve the power wheelchair with accessories. You say that the power wheelchair 
is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair with accessories. 
Our reviewer says that the requested power wheelchair is not medically necessary. Our physician reviewer 
found based on the provided records it is not clear that the patient has the physical or cognitive ability to safely 
use the requested power wheelchair. 
 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 power wheelchair with accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a power wheelchair with accessories.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 
setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The patient 
appears to be more stable and improving but requires additional short-term acute care hospital services that can 
safely be administered at the current facility until more appropriate for transfer to a lower level of care. The 
patient does not require services at the LTACH that are not already available at the current facility. Our 
physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve positron emission tomography (PET) scan of the brain. 
 
You asked the Plan to pre-approve the scan. You say that this is medicaly necessary. The Plan denied your 
request. The Plan says although the enrollee has trouble speaking, the results will not affect the treatment. 
 
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 scan. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found you are said to have speech changes. The provider has listed a primary progressive aphasis as one of the 
differential diagnosis. The enrollee does not readily meet the diagnostic criteria for both Alzheimer's disease or 
fronto-temporal dementia. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve positron emission tomography (PET) scan of the brain.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methotrexate. 
 
You asked the Plan to pre-approve Methotrexate. You say that this is medically necessary. The Plan denied 
your request. The Plan says coverage of this medication is the responsibility of your prescription drug plan. 
 
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 Methotrexate.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 3, 2021 billed with 
codes 81225, 81230, 81238, 81240, 81241, and 81291. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the 
services were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 3, 2021 billed with codes 81225, 81230, 81238, 81240, 81241, and 81291.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary. The Plan denied your request. The Plan says that an epidural steroid injection is not 
medically necessary. 
 
The Plan follows Medicare rules. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an epidural steroid injection. Our 
reviewer says that an epidural steroid injection is medically necessary. Our physician reviewer found that in 
this case, the enrollee has radiculopathy due to foraminal stenosis and pain which has lasted longer than 3 
months despite conservative therapy. The enrollee meets the coverage criteria for an epidural steroid injection.  
The requested procedure is medically reasonable and 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 an epidural steroid injection have been met. Therefore, we decided that the Plan 
has to pre-approve an epidural steroid injection.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission for acute inpatient rehabilitation (IRF) for the 
enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says skilled criteria for the acute inpatient rehabilitation level of care is not 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 pneumonia and respiratory failure. 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 medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 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 admission for acute inpatient rehabilitation (IRF) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received on March 22, 2022. 
 
You asked the Plan to pay for the drugs. You say that the medicine was prescribed. The Plan denied your 
request. The Plan says this is not a covered 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 pay for self-administered drugs received 
on March 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the provider is out-of-
network, and it was determined these services were not urgent or emergent. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compression device to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481 billed for date of service October 20, 
2021. 
 
You asked the Plan to pay for procedure code 87481. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 87481 is bundled into payment for code 87801. 
 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 87481 
is a column II code to column I code 87801. 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 procedure code 87481 billed for date of service October 20, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you would like additional 
transportation to be approved for coverage. The Plan denied your request. The Plan says you have utilized your 
benefit of 10 one-way trips for this plan year. The Plan also says that extra one-way trips cannot be approved. 
 
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 up to 10 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional trips. You say that you need additional trips to get to your 
appointments. The Plan denied your request. The Plan says the request was denied correctly. 
 
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 48 one-way trips per year.  We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99153) provided on August 9, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that the OPPS recognizes that CPT code 99153 is a 
practice expense (PE) only code and is not paid to the physician in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment for CPT 
code 99153 for services provided in the facility setting. Therefore, we decided that the Plan does not have to 
pay for the services (99153) provided on August 9, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the targeted genomic sequence analysis panel, solid organ neoplasm, 
cell-free DNA, analysis of 311 or more genes, interrogation for sequence variants, including substitutions, 
insertions, deletions, select rearrangements, and copy number variations (0239U) provided September 2, 2021. 
 
You asked the Plan to pay for the targeted genomic sequence analysis panel. You say that this service was 
medically necessary. The Plan denied your request. The Plan says that the date-of-service should be reported as 
the date the specimen was collected. 
 
The Plan must follow Medicare rules. Medicare rules say that in the case of a molecular pathology test 
performed by a laboratory other than a blood bank or center, or a test designated by CMS as an ADLT, the date 
of service must be the date the test was performed if the criteria in the Medicare Rules section of this letter are 
met. 
 
In this case the laboratory test performed is considered an ADLT. The sample in this case was collected during 
a hospital outpatient counter. Therefore, the date-of-service was correctly reported as the date the test was 
performed, September 2, 2021. Based on this information, we decided that Medicare rules for coverage of the 
targeted genomic sequence analysis panel have been met. Therefore, we decided that the Plan has to pay for the 
targeted genomic sequence analysis panel, solid organ neoplasm, cell-free DNA, analysis of 311 or more genes, 
interrogation for sequence variants, including substitutions, insertions, deletions, select rearrangements, and 
copy number variations (0239U) provided September 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.