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

We decided that the Plan does not have to pay for the colorectal cancer screening provided on March 18, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the colorectal cancer screening. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent.
Therefore, we decided that the Plan does not have to pay for the colorectal cancer screening provided on March 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) services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee needs to regain optimum 
independence and stabilization. The Plan denied your request. The Plan says the enrollee has no skilled nursing 
needs, and no acute skilled therapy needs. 
 
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 services. Our physician reviewer 
found that from a nursing perspective, the enrollee received oral medications, had stable vital signs, and her 
lungs were clear. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, the 
enrollee was at a contact guard to minimal assist level with functional mobility. She required varying assist 
with activities of daily living. Although there are identifiable skilled therapy service needs, the enrollee does 
not require skilled nursing or therapy services on a daily basis. She does not meet severity of illness or intensity 
of service criteria for an inpatient basis in a SNF 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the hot or cold packs therapy provided on May 19, 2021.
You asked the Plan to pay for the hot or cold packs therapy. You say that authorization is not needed, and the
claim should be reprocessed. The Plan denied your request. The Plan says codes G0283, 97110 and 97150 have
been approved for payment. Code 97010 remains denied as bundled services are not eligible for separate
reimbursement.
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 97010 is application of a modality to 1 or more areas; hot
or cold packs.
We find that CPT code 97010 is not supported in the medical record. Specifically, CPT code 97010 has a status
indicator of B. This means that CPT code 97010 is considered bundled and not separately payable. Based on
this information, we decided that Medicare rules for coverage of the hot or cold packs therapy have not been
met. Therefore, we decided that the Plan does not have to pay for the hot or cold packs therapy provided on
May 19, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more toward the eye exam, disposable contact lenses, contact lens fitting and fundus photography provided on June 10, 2021.
You asked the Plan to pay more toward the eye exam, disposable contact lenses, contact lens fitting and fundus photography. You say that you cannot afford to pay this bill and want to know why insurance did not cover it. The Plan denied your request. The Plan says the claims processed correctly.
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 one routine eye exam per calendar year and up to $200 for eyeglasses or contact lenses. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eye exam, disposable contact lenses, contact lens fitting and fundus photography have not been met. Specifically, the Plan paid the full cost of the eye exam and $200 toward the contact lenses. You are responsible for the full cost of the contact lens fitting and fundus photography as they are not covered benefits. Therefore, we decided that the Plan does not have to pay more toward the eye exam, disposable contact lenses, contact lens fitting and fundus photography provided on June 10, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Soliris. 
 
You asked the Plan to pre-approve Soliris. The Plan denied your request. The Plan says that the denied units 
are not medically necessary and reasonable. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
The file shows that 2880 units of Soliris was requested. The Plan has agreed to pre-approve 960 units for 9 
visits over 3 months. 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 additional units of 
Soliris. Our physician reviewer found that the requested use of Soliris is FDA approved for the treatment of 
atypical hemolytic uremic syndrome to inhibit complement-mediated thrombotic microangiopathy. Shiga 
negative and clinical criteria is met. Dosing is Induction: 900 mg weekly for 4 doses; Maintenance: 1,200 mg at 
week 5, then 1,200 mg every 2 weeks thereafter. The requested use is not listed as not indicated, not supported, 
or not recommended in any of the compendia. The documentation does support that the requested amount of 
Soliris is safe and effective and otherwise reasonable and necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Soliris have been met. Therefore, we decided that the Plan has to pre-approve 
Soliris.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory test provided on June 18, 2020. 
 
You asked the Plan to pay for the laboratory test. You say that the attached documents should be reviewed, and 
the claim processed toward payment. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the laboratory test provided on June 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.
You asked the Plan to pre-approve a ventilator. The Plan denied your request. The Plan says a ventilator with a setting that could be delivered by a BiPAP is not covered.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a ventilator. Our physician reviewer found that you have severe obstructive sleep apnea and morbid obesity. There is likely a component of obesity hypoventilation syndrome. The COPD is not severe enough to cause carbon dioxide (CO2) retention. Medicare does not cover a ventilator when used as BiPAP, and certain BiPAP devices are capable of providing the AVAPS mode of support. Therefore, the requested ventilator is not medically necessary at this time.
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 home ventilator.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xeomin.
You asked the Plan to pre-approve Xeomin. You say that the requested Xeomin is medically necessary. The Plan denied your request. The Plan says the requested Xeomin is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Xeomin. Our reviewer says that the requested Xeomin is not medically necessary. Our physician reviewer found based on the medical records provided and the Medicare-approved major drug compendia there is no documentation that Xeomin is Food and Drug Administration-approved for the enrollee's diagnosis. Based on the medical records provided the use of Xeomin for tension headache, occipital neuralgia and headache with migrainous features is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The use of Xeomin for tension headache, occipital neuralgia and headache with migrainous features 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 Xeomin have not been met. Therefore, we decided that the Plan does not have to pre-approve Xeomin.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit (99281) provided 
on July 16, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $90 for 
each Medicare-covered emergency room visit.  
 
You have been asked to pay $69.68 for the Medicare-covered emergency room visit provided. This is the 
Plan's allowed amount for this service, which is less than the applicable copayment. 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 the emergency room visit (99281) provided on 
July 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service 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 your medical conditions are stable and there are no complex nursing or rehabilitation 
needs. While the documentation does support a need for physical and/or occupational therapy, there is no 
documented need for an intensive, multi-disciplinary rehabilitation program. 
 
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. Specifically, medically necessary services can be 
obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. 
Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) 
admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies and materials provided from March 24, 2021, through May 3, 2021.
You asked the Plan to pay for the additional supplies and materials. You say that this code was established to report additional practice expenses incurred during a public health emergency and the claims should be reprocessed. The Plan denied your request. The Plan says bundled services are not eligible for separate reimbursement.
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 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.
We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the additional supplies and materials have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials provided from March 24, 2021, through May 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the present setting where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Myomo (L8702). 
 
You asked the Plan to pre-approve the Myomo. You say that the item is medically necessary. The Plan denied 
your request. The Plan says the item is not medically necessary. 
 
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 Myomo. Our reviewer says that the 
requested items is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the records show the patient is able to ambulate with a cane but has difficulty with dressing, they did not 
clearly include documentation of failure of bracing, exercise, or rehabilitation. The physical therapy notes state 
that, the patient had very good potential for reaching goals. 
 
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 Myomo have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Myomo (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the group two single power option (K0835) and 
accessories. 
 
You asked the Plan to pre-approve the group two single power option and accessories. You say that the items 
are medically necessary. The Plan denied your request. The Plan says the items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a group two sing power wheelchair is covered when 
all the criteria listed in the Medicare Rules section are met. 
 
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 group two single power option and 
accessories. Our reviewer says that the items are not medically necessary. Our physician reviewer found you 
are independent with bathing, dressing, grooming, toileting, and eating and you are independent with transfers 
and ambulation to 100 feet. 
 
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 group two single power option and accessories have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the group two single power option (K0835) 
and accessories.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nine (9) home health skilled nursing visits (CPT code 
G0299), for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the enrollee's medical conditions appear stable., there have been no recent 
changes to their treatment plan or their medications. The Plan states home skilled nursing visits were ordered to 
teach the enrollee about disease and medication management. The Plan states the enrollee previously approved 
visits should have allowed the enrollee's nurse to review their medical conditions, medication management, 
pain management, diet, and household safety with the enrollee. The Plan states the enrollee's records do not 
support the need for a skilled nurse to make more visits. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer 
found based on the medical records provided there is no documentation that additional skilled nursing services 
are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, 
or to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. 
Records do not document any acute unstable conditions or why the six previously approved skilled nursing 
visits have been inadequate to accomplish monitoring, teaching and assessment of disease processes, 
medication management and evaluation for any future therapy 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve nine (9) home health skilled nursing visits (CPT code G0299), for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the requested ventilator. You say that the enrollee will remain mobile and 
carry out more activities of daily living. The Plan denied your request. The Plan says ventilator settings that 
could be delivered by BiPAP is not covered for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested ventilator. Our physician 
reviewer found that the requested Life2000 system is not medically necessary. This system is not a true 
mechanical ventilator. It is a portable positive pressure system, intended to be used during activity. There is no 
convincing evidence that this device is beneficial in the treatment of lung disease. In addition, Medicare criteria 
are not met for a home ventilator.  
There is no documentation of the severity of the COPD with pulmonary function tests, and no documentation 
of carbon dioxide (CO2) retention. If the enrollee did retain CO2, BiPAP support at night could be beneficial.  
Medicare does not cover a ventilator when used as BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a home ventilator.