Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the coronavirus booster shot (0064A) provided on May 18, 2022. 
 
You asked the Plan to pay for the vaccine. You say that you were strictly to receive a Moderna coronavirus 
vaccine booster shot. You say that there was no other activity performed in this visit. You say that you are at 
high risk. You also say that this is supposed to be covered at no cost to the recipient. The Plan denied your 
request. The Plan says that this is not a covered service. 
 
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. Specifically, the documentation provided does not support the Plan's denial. The 
Evidence of Coverage clearly lists this as a covered service. Therefore, we decided that the Plan has to pay for 
the coronavirus booster shot (0064A) provided on May 18, 2022.  
 
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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires an IRF admission to facilitate 
increased independence. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI) (62321). 
 
You asked the Plan to pre-approve ESI. You say that the requested injection could help the enrollee with their 
activities of daily living (ADLs). You also say that this is medically necessary. The Plan denied your request. 
The Plan says the requested injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injections (ESIs) to treat non-specific 
low back pain (LBP), axial spine pain, complex regional pain syndrome, widespread diffuse pain, pain from 
neuropathy from other causes, cervicogenic headaches are considered investigational and therefore are not 
considered medically reasonable and necessary. 
 
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 ESI. Our reviewer says that the 
requested ESI is not medically necessary. Our physician reviewer found there is no documentation of radicular 
pain. The coverage criteria limitations indicate that epidural steroid injections for axial spine pain or 
widespread diffuse pain is not considered medically reasonable or necessary. Therefore, the reviewer found 
that the requested ESI 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 ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an epidural steroid injection (ESI) (62321).
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 services are medically necessary. The Plan 
denied your request. The Plan says the IRF services you are requesting do not meet the requirements for 
approval. 
 
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. 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. 
 
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 pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need rehabilitation due to being released from 
the hospital for pneumonia to return to caring for yourself independently. The Plan denied your request. The 
Plan says your records do not show that you need an intensive team for your care, medically necessary care 
may be provided safely in a different level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you are medically stable and do not need physician's supervision 3 times a week in an 
IRF, no acute rehabilitation nursing needs identified or documented. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment provided on June 25, 2022. 
 
You asked the Plan to pay for durable medical equipment. You say that you would like to be reimbursed for 
your recliner, it was needed for hip replacement recovery. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for durable medical 
equipment provided on June 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services billed under codes 87798 and 87481 
provided on September 14, 2022. 
 
You asked the Plan to pay for laboratory services billed under codes 87798 and 87481. You say that you are 
appealing the claim payment denial. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
billed under codes 87798 and 87481 provided on September 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bi-level respiratory assist device (E0470). 
 
You asked the Plan to pre-approve the bi-level respiratory assist device. You say that this device 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 bi-level respiratory assist device is covered for 
beneficiaries with Obstructive Sleep Apnea who meet coverage criteria for a single-level continuous positive 
airway pressure device and have had a trial of a single-level continuous positive airway pressure device that 
was proven ineffective based on a therapeutic trial conducted in either a facility or in a home setting. 
 
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 bi-level respiratory assist device. 
Our reviewer says that this device is not medically necessary. Our physician reviewer found the provided 
records do not document a single-level continuous positive airway pressure device (E0601) has been tried and 
proven ineffective based on a therapeutic trial conducted in either a facility or in a home 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 the bi-level respiratory assist device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a bi-level respiratory assist device (E0470).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 85007, 85014, 85041, & 85048 billed for 
date of service June 17, 2020. 
 
You asked the Plan to pay for procedure codes 85007, 85014, 85041, & 85048. You say that this service was 
medically necessary. The Plan denied your request. The Plan says the codes billed are not separately payable. 
 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 codes 
85007, 85041, & 85048 are column II codes to column I code 85025. Code 85014 is inclusive to the complete 
blood count billed (85025). 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 codes 85007, 85014, 85041, & 85048 billed for date of service June 17, 
2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 61783 billed for date of service October 27, 
2022. 
 
You asked the Plan to pay for procedure code 61783. You say that this is a separately reportable service. The 
Plan denied your request. The Plan says payment for code 61783 is bundled into payment for code 63047. 
 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 61783 
is a column II code to column I code 63047. 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 61783 billed for date of service October 27, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that BiPAP devices have proven ineffective at managing 
the enrollee's condition. The Plan denied your request. The Plan says a ventilator is not covered by Medicare 
for this purpose and the needed therapy could be delivered by a BiPAP device with average volume-assured 
pressure support (AVAPS) mode. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide continuous or 
bilevel positive airway pressure (CPAP or BiPAP) therapy, regardless of the underlying medical condition, 
shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Mounjaro subcutaneous injection. 
 
You asked the Plan to pre-approve Mounjaro. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage of self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Mounjaro 
subcutaneous injection.  
 Benefits for Mounjaro 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging provided on 
October 27, 2022. 
 
You asked the Plan to waive the copayment for myocardial perfusion imaging. You say that you feel that this 
service should be covered. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $325 
copayment for other Medicare-covered diagnostic radiology services, which includes nuclear cardiac imaging. 
 
You have been asked to pay a $325 copayment for myocardial perfusion imaging. This item/service falls within 
the other Medicare-covered diagnostic radiology services, which includes nuclear cardiac imaging 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 copayment for myocardial perfusion imaging provided on 
October 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99204 billed for date of service September 6, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says an incorrect 
procedure code was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99204 is office visit for the evaluation and management 
of a new patient. We find that CPT code 99204 is not supported. The case file shows that a new patient office 
visit was provided by a provider of the same specialty, in the same group practice within the previous 3 years.  
Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 99204 billed for date of 
service September 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 28, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 provided on March 28, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the records provided support the need for the requested 
drug. The Plan denied your request. The Plan says the enrollee has not tried and failed oral or injectable 
bisphosphonate. 
 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 Prolia. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the notes indicate that Reclast versus 
Prolia was discussed with the enrollee, but they do not say why the enrollee is a better candidate for Prolia. 
There is no documentation showing that the enrollee has a contraindication to Reclast or oral bisphosphonate. 
 
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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) and appliance 
provided on September 2, 2022. 
 
You asked the Plan to pay for the PCD and appliance. The Plan denied your request. The Plan says this item is 
not covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device (PCD) and appliance provided on September 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on March 1, 2022. 
 You asked the Plan to pay for the testing services. You say that the medical records warrant medical necessity. 
The Plan denied your request. The Plan says the panel does not meet the Medicare rules. 
 
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 87506 is not supported in the medical record. The rules say that coverage for up to 11 
targets will be covered if Clostridium difficile is one of the organisms tested for. In this case, there is no 
order/requestion from the treating physician to show that the testing was needed. The records show that the 
enrollee had already tested negative for Clostridium difficile. Based on this information, we decided that 
Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does 
not have to pay for the lab testing services provided on March 1, 2022.