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

 
We decided that the Plan does not have to pre-approve four additional hours of attendant care services. 
 
You asked the Plan to pre-approve the additional hours. You say that the hours should not be reduced. The Plan 
denied your request. The Plan says the assessment reveals a need for only 16 hours per week. 
 
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 additional hours. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided, and the Medicare guidelines there is no documentation 
that the enrollee meets criteria for 20 hours per week of attendant care services instead of 16, as defined by 
Medicare criteria. Personal attendant services (outside of a skilled home health nursing setting) are not a 
covered Medicare benefit. The provided records document no skilled needs.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the additional hours have not been met. Therefore, we decided that the Plan 
does not have to pre-approve four additional hours of attendant care services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stance flexion knee feature (L5845). 
 
You asked the Plan to pre-approve a stance flexion knee feature. You say that this is medically necessary. The 
Plan denied your request. The Plan says the requested part is included in the approved prosthetic knee. 
 
The Plan follows Medicare rules. Medicare rules say that a determination of the type of knee for the prosthesis 
will be made by the treating practitioner and/or the prosthetist based upon the functional needs of the 
beneficiary. Basic lower extremity prostheses include a single axis, constant friction knee. Other prosthetic 
knees are considered for coverage based upon functional classification. 
 
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 stance flexion knee feature. Our 
reviewer says that the requested item is not medically necessary. Our physician reviewer found the enrollee's 
approved knee unit already comes with a knee stance control therefore this request exceeds the enrollee's 
medical needs. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a stance flexion knee feature have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a stance flexion knee feature (L5845).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from November 26, 2021, through 
December 23, 2021, billed with code 3KC21. 
 
You asked the Plan to pay for the home health services as billed. You say that the reported HIPPS code is valid 
and correct. The Plan denied your request. The Plan says that payment is not allowed for this service because 
the PDGM code is missing or invalid. 
 
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 provided an appropriate denial rationale in this case. The 
reported HIPPS code is valid and appears on the HIPPS master list for the dates of service at issue. The Plan 
provided no specific reason to justify the assessment that the HIPPS code was not correct or valid. Without a 
valid rationale, we find that the denial of payment is not substantiated. Therefore, we decided that the Plan has 
to pay for the home health services provided from November 26, 2021, through December 23, 2021, billed with 
code 3KC21.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 SNF care. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found records do not document the need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. There is no 
documentation that the enrollee requires the services on an inpatient basis, only in a skilled nursing facility 
setting. Continued care in the acute inpatient rehabilitation facility is appropriate (and endorsed by the health 
plan) until the enrollee is stable to transfer to a lower level of care such as home with home health care or to an 
assisted living or long-term 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supplies (A4221, J1559, K0552) provided July 29, 2020 to 
August 19, 2020. 
 
You asked the Plan to pay for the supplies. You say that these items were medically necessary. The Plan denied 
your request. The Plan says the records do not support the codes 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. 
 
We find that CPT codes A4221, J1559, & K0552 are not supported in the medical record. Specifically, the 
clinical records provided do not support that the billed supplies were used. Procedure code J1559 was billed at 
70 units but drug regulations state the billed units should be 10,20,40 or 100. Based on this information, we 
decided that Medicare rules for coverage of the supplies have not been met. Therefore, we decided that the Plan 
does not have to pay for supplies (A4221, J1559, K0552) provided July 29, 2020 to August 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta. 
 
You asked the Plan to pre-approve Zilretta. You say that Zilretta is medically necessary. The Plan denied your 
request. The Plan says a trial of an intra-articular injection of a generic corticosteroid is required before 
alternatives can be considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Zilretta. Our reviewer says that Zilretta 
is not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred 
treatment or any reason it would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zilretta.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the cervical contour orthopedic pillow (CPT code 
E0190). 
 
You asked the Plan to pre-approve the pillow. You say that you need an orthopedic pillow due to severe pain 
even with treatment and physical therapy. The Plan denied your request. The Plan says most therapeutic 
pillows and cushions are not covered because they do not meet the contractual definition of durable medical 
equipment (DME) in that they are not durable and because they are not primarily medical in nature and not 
mainly used in the treatment of disease or injury. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. 
This item is available to the general public and would be helpful even to those who are not sick or injured. 
Therefore, we decided that the Plan does not have to pre-approve the cervical contour orthopedic pillow (CPT 
code E0190).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy provided on August 18, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for physical therapy. You say that these services were medically necessary. The Plan 
denied your request. The Plan says prior authorization was not obtained for these services to be provided out-
of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for occupational therapy provided on August 18, 
2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 SNF care. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee received oral medications, had 
stable vital signs and was treated for pain. There are no identifiable skilled nursing service needs. There are 
identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a 
daily basis. He does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99213) provided on January 26, 
2022. 
 You asked the Plan to pay for the outpatient office visit. You say that this service should be fully covered under 
your insurance plan. The Plan denied your request. The Plan says the copayment amount that you are being 
charged is correct. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers specialist office visits, and you are responsible for a $20 copayment. 
 
We looked at the file and the Plan's rules. The contract clearly states that you are responsible for a $20 
copayment for Medicare covered vision services. Based on this information, we decided that the Plan's rules for 
coverage of the outpatient office visit have not been met. Therefore, we decided that the Plan does not have to 
pay for the outpatient office visit (99213) provided on January 26, 2022.  
 
Please Note: If the contracted provider is charging you for any amounts beyond the applicable cost-sharing, 
please contact the Plan directly.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided on October 27, 2021 to 
November 10, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for drug testing services. You say that you would like to appeal the denial of the 
claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is required 
prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to 
pay for these items/services. Therefore, we decided that the Plan does not have to pay for drug testing services 
provided on October 27, 2021 to November 10, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endoscopic retrograde cholangiopancreatography (ERCP) 
services (43261, 43264, 43274, 43276) provided on September 5, 2019. 
 
You asked the Plan to pay for ERCP services. You say that the services at issue were billed correctly. The Plan 
denied your request. The Plan says rules for payment have not been met. 
 
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 asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for ERCP services. Our reviewer says that the services at issue 
do not meet criteria for payment. Our reviewer found that the procedure report does not support modifier 22 for 
increased procedural services. When reporting modifier 22, the medical record should include that the level of 
work was far more extensive than usually necessary for the procedure at issue in this case. Therefore, these 
procedures cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ERCP services have not been met. Therefore, we decided that the Plan does not have to pay for endoscopic retrograde cholangiopancreatography 
(ERCP) services (43261, 43264, 43274, 43276) provided on September 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound supplies provided on October 2, 2021 to December 2, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound supplies. You say that these wound supplies are separately billable 
and no authorization should be needed. The Plan denied your request. The Plan says [Enter plan denial 
rationale, e.g. "...rules for SNF care have not been met."] 
 
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. 
 You are not a network provider with the Plan. The Plan had network providers available who could have 
provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We 
found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the 
Plan does not have to pay for wound supplies provided on October 2, 2021 to December 2, 2021 by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
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 Dupixent for the enrollee.  
 
Benefits for this drug 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the over-the-counter (OTC) COVID-19 tests purchased from 
December 22, 2021, to January 6, 2022. 
 
You asked the Plan to pay for the OTC COVID-19 tests. You say that you were informed by member services 
that all at home COVID-19 tests would be reimbursed by your insurance plan. The Plan denied your request. 
The Plan says COVID-19 tests were not a covered benefit. 
 
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) tests for dates of service April 4, 2022 and 
after are paid for. OTC tests before April 4, 2022 are only covered if the Plan has a supplemental benefit for 
them. 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. Therefore, we decided that 
the Plan does not have to pay for the over-the-counter (OTC) COVID-19 tests purchased from December 22, 
2021, to January 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by a neurolytic agent. 
 
You asked the Plan to pre-approve destruction by a neurolytic agent. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that the thermal radiofrequency destruction of cervical, 
thoracic, or lumbar paravertebral facet joint (median branch) nerves are considered medically reasonable and 
necessary for patients who meet specific criteria. 
 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 destruction by a neurolytic agent. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found there is a lack of 
clear documentation showing 80% pain relief after each diagnostic block. Therefore, at this point, the request is 
deemed 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 destruction by a neurolytic agent have not been met. Therefore, we decided that 
the Plan does not have to pre-approve destruction by a neurolytic agent.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided November 17, 2021. 
 
You asked the Plan to pay for the ambulance response. You say that the ambulance response was necessary. 
The Plan denied your request. The Plan says this service is not covered when there is no transport. 
 
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 17, 2021. The ambulance benefit is a transportation benefit. The trip report in this case shows that the enrollee refused transport to the hospital and 
thus the wavier criteria is not met. 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, no transport (A0998) provided November 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided November 18, 2021. 
 
You asked the Plan to pay for the ambulance response. You say that someone called 911 when you passed out 
on a walk. The Plan denied your request. The Plan says this service is not covered when there is no transport. 
 
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 18, 2021. The trip report in this case 
shows that the enrollee refused transport to the hospital and thus the wavier criteria is not met. 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, no transport (A0998) provided November 18, 2021.