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

 
We decided that the Plan does not have to pay for the physician or allowed practitioner certification for 
Medicare-covered home health services under a home health plan of care (G0180) provided on February 16, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health service. You say that this service was medically necessary. The 
Plan denied your request. The Plan says prior authorization was not 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 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. Therefore, we 
decided that the Plan does not have to pay for the physician or allowed practitioner certification for Medicare-
covered home health services under a home health plan of care (G0180) provided on February 16, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on January 14, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on October 14, 2022. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for the services have not been met. Therefore, we decided that 
the Plan does not have to pay for the services provided on January 14, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, 
Ferrlecit, Infed and Venofer. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Injectafer. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the preferred drugs. The reviewer found that the documentation 
does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's 
preferred drugs. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on August 1, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that the claim was coded incorrectly 
because you were having chest pain after leaving work and you went to urgent care but this visit was not due to 
a work-related accident or injury. The Plan denied your request. The Plan says the services may be covered by 
your employer's insurance. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the emergency department visit have 
been met. Specifically, medical records were not provided to determine whether payment is due by the Plan. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit provided on 
August 1, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 1, 2022, to 
August 3, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from August 1, 2022, to 
August 3, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve additional mastectomy bras (L8000). 
 
You asked the Plan to pre-approve additional mastectomy bras. You say that you need these items. The Plan 
denied your request. The Plan says that the benefit maximum has been reached for this item. 
 
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 did not submit and documentation indicating you have already received 
the item. Therefore, we decided that the Plan has to pre-approve additional mastectomy bras (L8000).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (J9271) to be added to a regimen with Gemzar 
(J9201), and Carboplatin (J9045). 
 
You asked the Plan to pre-approve Keytruda. You say that the enrollee has had local recurrence 14 months out 
from adjuvant chemotherapy. You say that NGS testing shows negative PDL1. You also say that Keytruda 
should be added to current regimen of Carboplatin and Gemzar. The Plan denied your request. The Plan says 
the requested drug is not medically necessary. 
 
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 
request for Keytruda to be added to the enrollee's chemotherapy regimen is not medically necessary. Our 
physician reviewer found the requested use of Keytruda is not approved by the Food and Drug Administration 
for the enrollee's condition. The reviewer found that the major drug compendia or by clinical research that 
appears in a CMS-approved medical journal do not support the use of Keytruda for the enrollee's condition. Therefore, the reviewer found that the requested use of Keytruda is 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda (J9271) to be added to a regimen with Gemzar (J9201), and Carboplatin (J9045).
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 enrollee gets a temporary upgrade to a SNF from 
long-term custodial care based on the enrollee's physical condition and age. The Plan denied your request. The 
Plan says 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, in 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does 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) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve rental of a recliner chair. 
 
You asked the Plan to pre-approve a recliner chair. You say that you need a recliner chair to aid in healing after 
you have a shoulder replacement. The Plan denied your request. The Plan says the requested item is not a 
covered benefit.  
The Plan must follow Medicare rules. The rules say that seat lift chairs are not covered. Coverage is limited to 
a seat lift mechanism. The rules say that a seat lift mechanism is covered if all of the conditions listed in the 
Medicare rules section are met. 
 
We looked at the file and Medicare rules. Recliner chairs are excluded from coverage. The coverage is limited 
to the seat lift mechanism. Review of the file does not support that you meet all of the coverage listed above for 
a seat lift mechanism. 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. Based on this information, we decided that 
Medicare rules for coverage of a recliner chair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve rental of a recliner chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro brace (L8702) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a MyoPro brace. You say that the brace is medically necessary. The 
MyoPro would immediately restore the enrollee's arm function and range of motion by allowing them to 
volitionally control motors at the elbow and hand portions of the brace. The Plan denied your request. The Plan 
says the enrollee must use network providers for services. The Plan has confirmed that the necessary services 
may be obtained in-network. 
 
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 MyoPro brace (L8702) to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computer-assisted surgical navigation MAKOplasty. 
 
You asked the Plan to pre-approve computer-assisted surgical navigation MAKOplasty. 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 computer-assisted surgical navigation 
MAKOplasty. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found however, there are no large volume, long-term/high-
quality clinical studies that confirm clinical benefits (ultimate outcomes of functional improvement and pain 
reduction) of computer-assisted surgery over standard surgical approaches in total knee arthroplasty. There is 
no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested computer-assisted surgical navigation MAKOplasty, in this 
case, is 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 computer-assisted surgical navigation MAKOplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve computer-assisted surgical navigation 
MAKOplasty.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health physical therapy services. 
 
You asked the Plan to pre-approve home health services. The Plan denied your request. The Plan says the 
remaining 11 visits as it is not likely that more visits will be medically necessary. 
 
 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. 
 
The file shows that 14 visits were requested. The Plan has agreed to pre-approve 3 visits. 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 home health services. Our physician reviewer 
found that the enrollee does not have documented skilled physical therapy needs. The enrollee is functioning at 
a level commiserate with a lower level of care (i.e., home exercise program, outpatient therapy, layperson 
supervision). As such, the requested services are not medically necessary or reasonable. 
 
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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional home health physical therapy services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 93971 billed for date of service April 8, 2022. 
 
You asked the Plan to pay for procedure code 93971. You say that this was not a bundled charge. The Plan 
denied your request. The Plan says that the payment for procedure code 93971 is bundled into the payment for 
code 93970. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has provided no evidence to show that a conflicting service 
or a service to which 93971 would be bundled (93970) was provided and billed for this same date of service. 
Therefore, we decided that the Plan has to pay for procedure code 93971 billed for date of service April 8, 
2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88360 and 88365 billed for date of service 
March 4, 2022. 
 
You asked the Plan to pay for procedure code(s) 88360 and 88365. You say that these services were necessary 
and were coded correctly. The Plan denied your request. The Plan says this code is included in the facility 
payment and is not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88360 and 88365. 
This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88360 and 
88365. Based on this information, we decided that Medicare rules for coverage of procedure code 88360 and 
88365 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code(s) 
88360 and 88365 billed for date of service March 4, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on July 28, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.   
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided on July 28, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy and aide services. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee was making some progress 
with the services. The Plan denied your request. The Plan says the enrollee does not require a skilled therapist, 
and an aide is not covered without skilled services. 
 
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 requested services. Our physician 
reviewer found that the enrollee does not have documented skilled nursing or therapy needs. The enrollee's care 
needs appear to be custodial. As such, home health services, including associated home health aide services are 
not medically necessary or reasonable in this case. 
 
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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health physical therapy and aide services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve epidural steroid injections. 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 follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when specific criteria 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 epidural steroid injections. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found there is no 
documentation of an inability to tolerate noninvasive conservative care or medical documentation of failure to 
respond to four (4) weeks of noninvasive conservative care. The review has determined that the enrollee does 
not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections.