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

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 11, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
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 these 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 the laboratory services rendered on June 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on February 9, 2021. 
 
You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says there is not an established relationship between the 
enrollee and ordering provider. 
 
The Plan must follow Medicare rules. Medicare rules say that unless provided otherwise, other services 
included on the Medicare telehealth services list must be furnished using, at a minimum, audio and video 
equipment permitting two-way, real-time interactive communication between the patient and distant site 
physician or practitioner. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the office visit have not been met. Specifically, the documentation does not clearly indicate that the 
service was furnished using audio and video equipment permitting two-way, real-time interactive 
communication between the patient and distant site physician or practitioner. CPT code 99202 is not included 
on the list of codes which are appropriate for audio-only telehealth services. The documentation does not 
clearly show if this service was furnished using audio-only or audio-video communication. Therefore, we 
decided that the Plan does not have to pay for the office visit (99202) provided on February 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pain management injections. 
 
You asked the Plan to pre-approve pain management injections. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 pain management injections. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found radiofrequency ablation of the lateral sacral branches is considered an 
experimental/investigational procedure because of the wide variability of efficacy in the peer reviewed 
literature. Therefore, 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 pain management injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve pain management injections.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prochlorper 10mg tab. 
 
You asked the Plan to pre-approve Prochlorper 10mg tab. You say that the drug is medically necessary. The 
Plan denied your request. The Plan says this is an outpatient prescription drug that is self-administered. 
 
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 Prochlorper 10mg tab.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiidra drops. 
 
You asked the Plan to pre-approve Xiidra drops. You say that Xiidra is indicated for treatment of the signs and 
symptoms of their condition. You say that the enrollee has failed several methods of treatment and coverage 
should be reconsidered. The Plan denied your request. The Plan says this medication falls under Part D 
coverage and the member does not have a Part D pharmacy (drug) benefit with the Plan. 
  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xiidra drops.  
 
Benefits for Xiidra drops 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose 
monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 
met. 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (K0553).
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. The Plan denied your request. The Plan says the services are 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 physician reviewer found 
that you were admitted to the acute care hospital for a stroke with right-side weakness. Your medical problems 
are stable. You do not require treatment by multiple therapies in an intensive rehabilitation therapy program. 
While you have a need for physical and/or occupational therapy, there is no documentation of a need for an 
intensive 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. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services received under hospice provided to the enrollee 
from July 12, 2021, to July 30, 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 the services should be billed under Original Medicare. 
 
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 services received under hospice provided to the enrollee from 
July 12, 2021, to July 30, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an outpatient diagnostic service provided on June 24, 
2021. 
 
You asked the Plan to waive the copayment for an outpatient diagnostic service. You say that you would like to 
dispute the cost share. The Plan denied your request. The Plan says that a $0 copay was charged for this 
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. The Plan failed to forward a proper Explanation of Benefits for June 24, 2021. 
Therefore, we decided that the Plan has to waive the copayment for an outpatient diagnostic service provided 
on June 24, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the primary care visit you had with an out-
of-network doctor on January 21, 2021. 
 
You asked the Plan to waive the copayment for the out-of-network primary care visit. You say that you thought 
this provider was in-network. The Plan denied your request. The Plan says this copayment was charged 
correctly.  There are no records showing that you contacted the Plan prior to this visit to confirm the provider's 
network status. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for out-of=network primary care visits.  
 
You have been asked to pay a $40 copayment for the out-of-network primary care visit. 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 primary care visit you had with an out-of-network doctor on 
January 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tramadol, 50mg tablets. 
 
You asked the Plan to pre-approve Tramadol, 50mg tablets. You say that she has been taking Tramadol for 
over two years and the treatment has been successful. You say that it is medically necessary for the patient to 
continue with Tramadol. The Plan denied your request. The Plan says this medication falls under Part D 
coverage and the member does not have a Part D pharmacy (drug) benefit with the Plan. 
  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tramadol, 50mg tablets.  
 
Benefits for Tramadol, 50mg tablets 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve at the in-network cost share rate an office visit (99214) 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve at the in-network cost share rate an office visit. You say that this care can 
only be obtained with an OON provider. The Plan denied your request. The Plan says there are in-network 
providers that can provide the medical care you require. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that enrollees can receive care from either a network provider or an out-of-network provider. If the 
enrollee sues an out-of-network provider, the share of costs for covered services may be higher. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has agreed to cover these 
services at the OON copayment rate. The Plan has network providers available who can provide the 
items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve at the 
in-network cost share rate these items/services because they are not available in-network. Therefore, we 
decided that the Plan does not have to pre-approve at the in-network cost share rate an office visit (99214) to be 
provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve Retacrit. You say that the enrollee requires Retacrit to treat anemia as all 
other causes of anemia have been ruled out. You say that the goal of therapy is to prevent the need for 
transfusions or alloimmunization. The Plan denied your request. The Plan says the drug should be requested 
through the pharmacy benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Retacrit.  
 
  Benefits for Retacrit 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: 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 necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not 
a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a chair with a seat lift mechanism 
 
You asked the Plan to pre-approve a chair with a seat lift mechanism. You say that the requested seat lift 
mechanism is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested seat lift mechanism. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
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 a chair with a seat lift mechanism. Our 
reviewer says that the enrollee does not meet criteria for the requested seat lift mechanism. Our physician 
reviewer found the documentation does indicate multifocal advanced disease in right hip and knees. The 
medical progress notes do include a seat lift in the course of treatment. The seat lift is not likely to (a) effect 
improvement in the enrollee's condition; or (b) arrest or retard deterioration in the enrollee's condition.  The records do show that the enrollee is incapable of standing without assist. The enrollee is noted to be 
wheelchair bound, therefore not ambulatory. The enrollee does not meet the criteria for the seat lift mechanism 
per Medicare Local Coverage Determination (LCD) L33801, Seat Lift Mechanisms. 
 
The rules also say that seat lift chairs are not covered. 
 
Although a seat lift chair may be appropriate, Medicare does not cover this item and the Plan must provide 
coverage only for items that Medicare covers. 
 
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 chair with a seat lift mechanism have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a chair with a seat lift mechanism
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the chest ultrasound you had at an 
outpatient hospital on May 27, 2021. 
 
You asked the Plan to waive the deductible for the ultrasound. You say that this test is part of your preventive 
care and you have no choice.  You said that you do not feel as though you should be charged for this since your 
doctor asks you to have it every year and you should be covered under your insurance. The Plan denied your 
request. The Plan says you were charged this deductible correctly.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $395 deductible which applies to outpatient hospital services.  
 
You received the ultrasound at an outpatient hospital. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $395 deductible which applies to outpatient hospital services. This cost 
sharing is a contractual obligation that had not been met at the time the ultrasound was received on May 27, 
2021. Therefore, we decided that the Plan does not have to waive the deductible for the chest ultrasound you 
had at an outpatient hospital on May 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flex-walk foot (L5981) for use with an approved 
prosthesis. 
 
You asked the Plan to pre-approve the flex-walk foot. You say that the requested components should be 
approved. The Plan denied your request. The Plan says the enrollee does not have the required functional level 
for this foot. 
 
The Plan follows Medicare rules. Medicare rules say that a prosthetic foot described by code L5981 may be 
covered for level 3 ambulators.  
 
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 flex-walk foot. Our reviewer says that the criteria for the requested prosthetic foot are not met. Our physician reviewer found the documentation 
does not support that the patient is a K3 level ambulator as he uses a walker for ambulation.  
 
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 flex-walk foot have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a flex-walk foot (L5981) for use with an approved prosthesis.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 11, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed these services with an incorrect place of service. 
 
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 provided on May 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Livalo. 
 
You asked the Plan to pre-approve Livalo. You say that Livalo is medically necessary. The Plan denied your 
request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Livalo.  
 
 
 Benefits for Livalo may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.