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

 
We decided that the Plan does not have to pay for the home health services provided from October 16, 2021, to 
November 14, 2021. 
 
You asked the Plan to pay for the home health services. You say that you always follow the guidelines as 
communicated by the plan. The Plan denied your request. The Plan says a RAP claim was not submitted within 
5 days of the start of care. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, the record indicates the RAP was not submitted within 5 days of the from the start of care date, October 16, 2021. Therefore, we decided that the 
Plan does not have to pay for the home health services provided from October 16, 2021, to November 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that 
were issued on October 28, 2021. 
 
You asked the Plan to pay for the compression stockings. You say that you have congestive heart failure and 
these stockings were prescribed by your doctor to relieve heart problem symptoms. The Plan denied your 
request. The Plan says this item is not a Medicare covered benefit. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6530 that were issued on October 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous anesthetic infusion by catheter to the lumbar 
plexus provided on August 24, 2021, billed with code 64449-59-RT. 
 
You asked the Plan to pay for the anesthetic infusion to the lumbar plexus. You say that this was billed with 
modifier -59 because it is a separately reimbursable component to the main procedure. The Plan denied your 
request. The Plan says the use of modifier -59 is not supported in this case. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, the record shows that anesthesia was started at 9:55AM and stopped at 11:31AM. The 
lumbar plexus infusion was begun at 10:06AM as part of initialization of anesthesia. Modifier -59 would be 
appropriate only if this injection was provided after anesthesia was complete for postoperative pain 
management. Based on this information, we decided that Medicare rules for coverage of services billed with a -
59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for the continuous anesthetic infusion by catheter to the lumbar plexus provided on August 24, 2021, billed with code 64449-59-
RT.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Orthosis. 
 
You asked the Plan to pre-approve a MyoPro Orthosis. You say that you had a stroke 4 years ago and your left 
arm and hand do not work normally. You say that you cannot do anything by yourself. You say that the 
requested device is not experimental, and it works for stroke victims. You say that this is a matter of life or 
death. The Plan denied your request. The Plan says there is insufficient published evidence to assess the impact 
on health outcomes or patient management associated with the use of the MyoPro orthosis for upper extremity 
paralysis/paresis after stroke. The Plan says that this device is considered to be experimental/investigational. 
 
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 a MyoPro Orthosis. Our reviewer says 
that a MyoPro Orthosis is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the MyoPro is not known to be effective, based on scientific evidence, professional standards 
and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use 
based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will 
improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual 
activities. 
 
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 MyoPro Orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro Orthosis.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care to be provided by a 
network facility. 
 
You asked the Plan to pre-approve the SNF care. You say that the enrollee is ready to be discharged to a SNF 
because she is not independent and needs 24/7 care. The Plan denied your request. The Plan says authorization 
denied because the SNF care is not medically necessary, and the enrollee's needs can be met at a lower level of 
care such as home with home health, residential care, or home with close follow-up with their doctor.  
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 the SNF care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found based on the documentation provided, 
the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. 
The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to 
establish a maintenance program or to prevent deterioration of the enrollees condition. The enrollees care 
needs, custodial and intermittent, can, as a practical matter, be provided at a lower level of care (ex. home, 
assisted living, long-term 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) care to be provided by a network facility.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99213) with an 
ophthalmologist provided on December 16, 2021. 
 
You asked the Plan to waive the copayment for the office visit with a specialist. You say that this was a routine 
visit and should be covered with a $0 copay. The Plan denied your request. The Plan says this claim was 
processed correctly, and your copayment was assessed in accordance with your contract. Routine exams are for 
checking vision, updating prescriptions and screening for eye disease in an enrollee who has no symptoms. The 
visit in question was provided to treat and discuss an ocular allergy condition, and medicine was prescribed 
during this visit. This is outside the scope of what is covered during a routine exam. 
 
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 $35 
copayment for each specialist visit.  You have been asked to pay a $35 copayment for the office visit with a specialist. An ophthalmologist is a type 
of specialist, and the record shows that the services provided were not considered routine by Medicare 
definition. 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 office visit (99213) with an 
ophthalmologist provided on December 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 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: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the X-ray provided on December 27, 2021. 
 
You asked the Plan to waive the copayment for the X-ray. You say that you were charged incorrectly. The Plan 
denied your request. The Plan says that the copayment amount charged is correct. 
 
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 enrollees must pay a $0 copayment for X-rays that are performed in an 
Independent Diagnostic Testing Facility (IDTF).  
 
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 the 
cost-sharing amount you have been asked to pay. Specifically, the Plan did not provide evidence of the place of 
service for the X-ray was provided. Without identifying the place of service, we cannot determine whether the 
$0 copayment or $100 copayment is appropriate for this claim.  
 
The Plan says you must pay $34.82 for the X-ray. Based on the Plan contract, however, you cannot be asked to 
pay more than a $0 copayment for the X-ray. Therefore, we decided that the Plan has to waive the copayment 
for the X-ray provided on December 27, 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 definitive drug testing provided on September 13, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON drug testing. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says the testing was ordered by an OON provider and performed by an 
OON laboratory. No authorizations are on file for any of the OON services. The services are available from 
network providers. 
 
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 definitive drug testing provided on September 
13, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services provided on February 11, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were ordered by the enrollee's 
physician. The Plan denied your request. The Plan says that the services were provided out-of-network and 
were not approved in advance. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for lab services by a contract provider. The file does not show that the plan provided 
notice that lab services would not be covered. Under Medicare rules, this means lab services is considered 
approved by the plan. Therefore, we decided that the Plan has to pay for the lab services provided on February 
11, 2021.  
 
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 lab services were ordered by the enrollee's physician. The Plan did not provide any evidence that 
this ordering physician is in-network or out-of-network to support a denial of payment for this service.  
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF care. You say that you require SNF care. The Plan denied your request. 
The Plan says you do not meet criteria for coverage of SNF therapy services. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that you do not have daily skilled nursing 
needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 
skilled nursing facility (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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory pathogen by nucleic acid testing provided on 
September 27, 2021, billed with codes 87541, 87581, 87640, 87651, and 87798. 
 
You asked the Plan to pay for the pathogen testing as billed. You say that this was medically necessary testing 
that should be paid. The Plan denied your request. The Plan says these codes were billed on the same date of service as 81225 from the same provider. These codes are only payable on the same date as 81225 when a 
modifier is used. 
 
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 87541, 87581, 87640, 87651, and 87798 are column II codes to 
column I code 81225. 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 the respiratory pathogen by nucleic acid testing provided on September 27, 2021, billed with 
codes 87541, 87581, 87640, 87651, and 87798.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) and the infrared 
therapy (97076) rendered by the out-of-network (OON) provider on November 16, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the acupuncture treatment (97810, 97811) and the infrared therapy (97076) 
rendered by the out-of-network (OON) provider on November 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-invasive home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested device is medically necessary 
The Plan denied your request. The Plan says the requested device does not meet criteria. 
 
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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
COPD, although there are no pulmonary function tests to confirm. The enrollee was recently hospitalized with 
pneumonia and exacerbation of HFpEF as well as presumed COPD. CO2 retention has been documented on 
ABG. There may be an element of obesity-hypoventilation syndrome. The enrollee may benefit from bipap 
with AVAPS mode during sleep. But Medicare does not pay for a ventilator when used as bipap. There is no 
documented failure of bipap in the AVAPS mode as an outpatient when stable. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a non-invasive home ventilator (E0466).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) scan of the lumbar 
spine (72158). 
 
You asked the Plan to pre-approve MRI scan of the lumbar spine. You say that this imaging is medically 
necessary. The Plan denied your request. The Plan says that the criteria for coverage have not been met for the 
imaging services. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 MRI scan of the lumbar spine. Our 
reviewer says that the requested MRI is not medically reasonable and necessary. Our physician reviewer found 
the patient is an 88-year-old female with low back pain, intervertebral disc degeneration in lumbar region, and 
status post fall in November 2021. An MRI was performed in February 2022, already revealing severe arthritis 
in her back vs possible discitis/osteomyelitis. Repeat MRI lumbar spine was requested as infectious disease 
specialist recommended it to follow-up on possible discitis/osteomyelitis. However, the patient had normal 
vitals, no acute findings on labs, and inconsistent physical exam findings to suggest an infectious process was 
present or that the patient had significant enough worsening or change to justify repeat MRI in general. 
Therefore, without sufficient support made for this request, the repeat lumbar MRI will be considered 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 MRI scan of the lumbar spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve magnetic resonance imaging (MRI) scan of the lumbar spine (72158).