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

 
We decided that the Plan does not have to pre-approve Ruxience. 
 
You asked the Plan to pre-approve Ruxience. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Ruxience. Our reviewer says that the 
requested use of Ruxience is not supported. Our physician reviewer found Ruxience is not Food and Drug 
Administration-approved for the enrollee's diagnosis of immune thrombocytopenic pupura. The use of 
Ruxience at a dosage of 375 milligrams per square meter weekly for 8 weeks for immune thrombocytopenic 
pupura is not indicated, supported or recommended in any of the compendia. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ruxience have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ruxience.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction procedure (92015) provided on August 26, 
2021. 
 You asked the Plan to pay for an eye refraction. You say that the provider at issue is an in-network provider. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 these services when provided as part of a routine eye exam. 
 
We looked at the file and the Plan's rules. The case record indicates that the service at issue was provided as 
part of a non-routine medical eye exam by an ophthalmologist. Based on this information, we decided that the 
Plan's rules for coverage of an eye refraction have not been met. Therefore, we decided that the Plan does not 
have to pay for an eye refraction procedure (92015) provided on August 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided February 10, 2022 to 
February 23, 2022. 
 
You asked the Plan to pay for the acupuncture services. You say that you are appealing the decision to not 
allow payment for your dry needling sessions. The Plan denied your request. The Plan says If you go to a 
provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services 
you receive. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the acupuncture services provided 
February 10, 2022 to February 23, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from October 4, 2021 to 
October 6, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says that the provider would need a corrected claim due to the services 
being observation and not an inpatient stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee presented for short of breath and was diagnosed with a large pleural effusion. INR 
(international normalized ratio) was noted to be elevated, which precluded immediate thoracentesis for the 
pleural effusion. The record support that at the time of inpatient admission the admitting physician reasonably 
expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span 
two midnights and medically necessary care did span a time period of more than two midnights. Inpatient 
admission was 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from October 4, 2021 to October 6, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit provided June 17, 2019 
 
You asked the Plan to pay for the emergency visit. You say that you request review of the attached POTF and 
expect this claim to be processed for immediate payment. The Plan denied your request. The Plan says the 
claim was submitted past the timely filing limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the emergency visit was not filed until December 09, 2021. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the emergency department visit provided June 17, 2019
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on October 12, 
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 modifier W is considered invalid in this case. 
 
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 A0427 is "Ambulance service, advanced life support, 
emergency transport, level 1 (als 1 - emergency)." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the services were billed 
incorrectly, as the ET3 does not apply for Medicare Advantage members per CMS. 
 
We looked at this coder'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 ambulance services provided to the enrollee on October 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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 Centers for Medicare & Medicaid Services 
(CMS) National Coverage Determinations Manual (CMS Pub. 100-03) in Chapter 1, Part 4, Section 280.1 
stipulates that ventilators (E0465, E0466, and E0467) are covered when specific criteria are 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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. There are listed diagnoses of chronic obstructive pulmonary disease (COPD) and sarcoidosis, but no 
pulmonary function tests. There is no documentation of carbon dioxide (CO2) retention while the enrollee is 
stable as an outpatient. There is no failure of bilevel positive airway pressure (BiPAP) as an outpatient. 
Medicare does not cover a home 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to waive the copayment for ambulance services provided on September 28, 2019. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you went from one 
hospital to another, and you feel the service should be covered. The Plan denied your request. The Plan says 
that the copayment applied was correct. 
 
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 breakdown of charges towards the enrollees 2019 
out-of-pocket maximum. Therefore, we decided that the Plan has to waive the copayment for ambulance 
services provided on September 28, 2019.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interim partial denture (D5820) provided on July 28, 
2021. 
 
You asked the Plan to pay for the dental service. You say that the provider did not advise that the denture 
would not be covered. You also say that you do not have the resources to pay for it. The Plan denied your 
request. The Plan says the interim partial denture is not a covered service. 
 
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 interim partial denture is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
interim partial denture (D5820) provided on July 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81162, 81194, 81206, 81292, 81295, 81298, 
81301, 81317, 81321, 81401) provided June 14, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (81162, 81194, 81206, 81292, 81295, 81298, 81301, 81317, 
81321, 81401) provided June 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided 
September 3, 2021. 
 
You asked the Plan to pay for a pneumatic compression device. You say that these services are not paid to you 
by the facility and payment for items used should not be included with payment to the facility. The Plan denied 
your request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein 
thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided September 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device (E0730) provided on January 30, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the TENS device. You say that prior to rendering services you were informed by 
the Plan's authorization department that an authorization was not required. The Plan denied your request. The 
Plan says enrollees must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 
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 the transcutaneous electrical nerve stimulation 
(TENS) device (E0730) provided on January 30, 2022 by an out-of-network (OON) provider.
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 do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation 
that you 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient hospital services provided to the enrollee 
from December 14, 2021, to December 15, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says the services provided appear to have been appropriate for observation 
level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the patient was sent to the emergency department by her cardiologist's office due to 
reported chest, jaw, and left arm discomfort. Initial workup ruled out acute coronary syndrome, but the patient 
required overnight testing to confirm. Vitals signs remained stable/normal, pain was not severe. Based on the 
provided documentation, it was not expected that the patient required hospital care that would likely cross 2 
midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for acute inpatient hospital services provided to the enrollee from December 14, 
2021, to December 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99213) photodynamic therapy 
(96567) Aminolevulinic acid hcl for topical administration (J7345) destruction of premalignant lesions (17000, 
17003) provided on December 7, 2021 to January 4, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visits. You say that the provider had submitted to the Plan for approval 
however, before approval was received you booked the appointment to begin the treatment. Between the dates 
you were informed that this would be partially covered by the Plan. The Plan denied your request.  The Plan says enrollees must receive their medical services from an in-network provider with the exception 
being urgent or emergent services. Non-emergent services with non-contracted providers require prior 
authorization before services being rendered. 
 
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 the outpatient office visit (99213) photodynamic 
therapy (96567) Aminolevulinic acid hcl for topical administration (J7345) destruction of premalignant lesions 
(17000, 17003) provided on December 7, 2021 to January 4, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness telehealth visit (G0439) provided on 
March 24, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the telehealth. You say that the CG modifier was added per the Plan's telehealth 
guidelines. This is a covered benefit. The Plan denied your request. The Plan says enrollees must receive their 
telehealth services from an in-network 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 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 the annual wellness telehealth visit (G0439) 
provided on March 24, 2021 by an out-of-network (OON) provider.