Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement prosthetic socket equipment. 
 
You asked the Plan to pre-approve replacement prosthetic socket equipment. You say that you would like 
reconsideration because the requested replacement is medically necessary. The Plan denied your request. The 
Plan says the requested replacement exceeds your needs. 
 
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 replacement prosthetic socket 
equipment. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case.  Our physician reviewer found the internal medicine progress note does not support that you require a 
replacement socket. You received a replacement socket on August 31, 2021 and the documentation indicates 
you have a non ataxic gait and there is no evidence that a replacement socket is needed on this progress note. 
There are no updated medical progress notes from your treating medical provider that support the Licensed 
Prosthetist/Orthotist evaluation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of replacement prosthetic socket equipment have not been met. Therefore, we 
decided that the Plan does not have to pre-approve replacement prosthetic socket equipment.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methotrexate 2.5mg tablet for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this self-administered drug does not fall under Part C coverage. 
 
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 Methotrexate 2.5mg tablet 
for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a ventilator. The Plan denied your request. The Plan says the requested 
ventilator setting that could be delivered by 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 a diagnosis of asthma and COPD, but the spirometry indicates restrictive lung disease. An 
arterial blood gas (ABG) study done showed at least partially venous blood. Thus, chronic carbon dioxide 
retention is not established. Medicare does not cover a home ventilator when used as a BiPAP. Therefore, a 
home ventilator 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a portable ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a seat lift mechanism and chair purchased from an out-of-
network provider on October 15, 2021. 
 
You asked the Plan to pay for a seat lift mechanism and chair. You say that this should be fully reimbursed 
apart from your coinsurance. The Plan denied your request. The Plan says the allowable amount applied to your 
deductible. 
 
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 $750 deductible which applies to most out-of-network items and 
services. The rules also say that seat lift chairs are not covered. Coverage is limited to a seat lift mechanism. 
 
The item you asked the Plan to pay for was purchased from an out-of-network provider. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to most out-
of-network services. This cost sharing is a contractual obligation that had not been met at the time a seat lift 
mechanism and chair was received on October 15, 2021. The Plan applied the allowed amount for the seat lift 
mechanism to your deductible. 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. The Plan is not responsible for the 
difference in the Medicare allowable amount for the mechanism and the total amount you paid for the 
mechanism and chair together. Therefore, we decided that the Plan does not have to pay for a seat lift 
mechanism and chair purchased from an out-of-network provider on October 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99223) provided on August 14, 2021. 
 
You asked the Plan to pay for initial hospital care. You say that this service was billed correctly and is 
supported in the record. The Plan denied your request. The Plan says this service is not supported as 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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components; A comprehensive history; A 
comprehensive examination; and Medicare decision making of high complexity. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for initial hospital care. Our reviewer says that the evaluation 
and management documentation does not support the level of care for 99223. Our reviewer found based on the 
documentation provided, CPT 99221 would be a more appropriate code to report. 
 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of initial hospital care have not been met. Therefore, we decided that the Plan does 
not have to pay for initial hospital care (99223) provided on August 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on August 31, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that you never received a denial, only a bill. The 
Plan denied your request. The Plan says since there was no transport provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 31, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on August 31, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the enrollee needs this immunotherapy and is 
scheduled for treatment. The Plan denied your request. The Plan says the denial of authorization for this drug is 
correct, because the clinical value and effectiveness of Keytruda has not been demonstrated in the enrollee's 
circumstances. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Keytruda. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested use of Keytruda. Our physician reviewer found 
Keytruda is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis of non-metastatic 
disease. The requested use of this drug is not supported by one of the major drug compendia or by clinical 
research appearing in a Medicare-approved medical journal. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Keytruda.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (82310,83540, 83550 and 84100) 
provided on August 3, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because 
there is no contractual agreement indicating that these codes are included in the dialysis rate. The Plan denied 
your request. The Plan says the dialysis center is responsible for laboratory services related to the treatment of 
ESRD. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services (82310,83540, 83550 and 84100) provided on August 3, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from November 1, 2020, to November 3, 2020. 
 
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 there is no five day MDS assessment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
These services require a valid five day MDS assessment with an Assessment Reference Date (ARD) set 
between October 2, 2020 to October 9, 2020. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for skilled 
nursing facility (SNF) services provided to the enrollee from November 1, 2020, to November 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve pneumatic compression device. You say that the treating physician has 
ordered this specific lymphedema pump only. The Plan denied your request. The Plan says the denial of 
authorization for this device is correct, because this provider is out-of-network with the Plan and this device 
can be obtained from an in-network equipment supplier. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers.   
The requested provider in this case is not a network provider with the Plan. 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 these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compression device (PCD) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for parenteral nutrition administration kit, per day (B4224) and 
parenteral nutrition solution (B4197) provided April 10, 2021 to April 15, 2021. 
 You asked the Plan to pay for the parental nutrition supplies. You say that your claim was denied because of 
misquoted benefits that were given to you on 10/20/20.These benefits should fall under DME supplies for 
parental nutrition. The Plan denied your request. The Plan says the enrollee's benefit has been exhausted. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that the Plan's 
annual limit is $5,000. Costs in excess of this limit are the responsibility of the enrollee. 
 
You have asked the Plan to pay $3307.59 for the parental nutrition supplies.  The rules say that Medicare does 
not pay for nutritional supplementation however, the Plan had a benefit that exceeded Medicare rules. In this 
case, the Plans rules apply. The point of Service benefit does not extend to all covered services. The Plan's 
annual limit is $5,000. Costs in excess of this limit are the responsibility of the enrollee. The records show that 
the benefit has been exhausted.. Therefore, we decided that the Plan does not have to pay for parenteral 
nutrition administration kit, per day (B4224) and parenteral nutrition solution (B4197) provided April 10, 2021 
to April 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not 
need to be seen by a rehabilitation doctor at least 3 times a week for evaluation of functional and medical goals 
and progress. 
 
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 enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollees care needs can be met at a lower 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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 the enrollee received oral medications and had 
stable vital signs. She was at an independent to stand by assist level for functional mobility including gait. The 
enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing provided on October 13, 2020. 
 
You asked the Plan to pay for the drug testing. You say that this is medically necessary testing. The Plan 
denied your request. The Plan says the appropriate POS code was not reported on this claim. 
 
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 drug testing 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 definitive drug testing provided on October 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom Ottobock C brace. 
 
You asked the Plan to pre-approve custom brace. You say that with the use of the brace the enrollee is able to 
be productive and have better quality of life while not being to a wheelchair. The Plan denied your request. The 
Plan says the denial of authorization for this item is correct, because this is experimental/investigational and 
exceeds the enrollee's needs. 
 
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 custom brace. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this item exceeds the enrollee's needs as insufficient evidence in the literature that this improves 
ambulation compared to standard knee-ankle-foot orthoses (KAFOs) or that this will be safe for the enrollee to 
use. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of custom brace have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a custom Ottobock C brace.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cytopathology/immunohistochemistry testing provided 
on September 22, 2021. 
 
You asked the Plan to pay for the pathology testing. You say that this was medically necessary testing and 
should be paid. The Plan denied your request. The Plan says an appropriate POS code was not reported based 
on the location where the sample was taken. 
 
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 pathology testing 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 cytopathology/immunohistochemistry testing provided on September 
22, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy visits. 
 
You asked the Plan to pre-approve home health visits. You say that you need physical therapy to show you 
some exercises once your sling is off. The Plan denied your request. The Plan says the denial of authorization 
for home health care is correct. 
 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 home health visits. Our reviewer says 
that you do not meet the Medicare criteria for the requested home health care. Our physician reviewer found 
there is no documentation that further skilled therapy services are required to effectively provide treatment, 
care, or services needed to improve your level of function, or to establish/perform a maintenance 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 home health visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (82310, 82728, 83540, 83550, 83970 
& 84100) provided on October 6, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because 
there is not a contractual agreement in place indicating that these codes are included in the dialysis rate. The 
Plan denied your request. The Plan says the laboratory test is considered to be included in the ESRD PPS and is 
the responsibility of the ESRD facility. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services (82310, 82728, 83540, 83550, 83970 & 84100) provided on October 6, 2021.