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

 
We decided that the Plan does not have to pre-approve Oxycodone 10MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says Oxycodone is a self-administered drug and does not fall under Part B 
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 Oxycodone 10MG tablet.   
Benefits for the medication 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid (V5261) provided on September 14, 2021. 
 
You asked the Plan to pay for the hearing aid. You say that your contract does not specify that hearing aids 
need to be purchased from anywhere in particular, and the Plan's specified vendor charges twice as much. The 
Plan denied your request. The Plan says hearing aids are only covered by your benefit when they are purchased 
from the Plan's specified vendor. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan has 
partnered with a specific routine hearing vendor to provide your hearing exam and hearing aid benefit. All 
appointments must be scheduled through this specified vendor. If you choose to schedule an appointment 
directly with a provider, your services will not be covered.  
 
We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's hearing vendor 
network, and there is no record of you having called the specified vendor prior to arranging a hearing aid 
appointment. Based on this information, we decided that the Plan's rules for coverage of the hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid (V5261) provided on 
September 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder test provided to the enrollee on August 4, 
2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare says tests with no relation to a medical diagnosis of disease for the health of the patient 
are not a benefit. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the National Comprehensive Care Network (NCCN) Guidelines only recommend the use of this test 
during surveillance of high-risk muscle-invasive bladder cancer. This patient has hematuria and has not had an 
initial standard workup for such nor has a formal diagnosis of muscle-invasive bladder cancer. There is 
insufficient high quality evidence supporting use of this test in the setting of hematuria over standard workup at 
this time. Therefore, this request for CxBladder will be considered 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 the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the CxBladder test provided to the enrollee on August 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Lite test strips.  
You asked the Plan to pre-approve Freestyle Lite test strips. You say that you have been using the requested 
test strips for many years. The Plan denied your request. The Plan says the requested brand is not covered by 
the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Advantage (MA) plans may specify 
brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the 
DME to only those preferred brands and manufacturers. The Plan contract states that the Plan will only cover 
Lifescan test strips and monitors. 
 
We looked at the file and Medicare rules. No medical reasoning has been provided to support that you cannot 
use the Plans preferred brand of glucose monitor and test strips. Based on this information, we decided that 
Medicare rules for coverage of Freestyle Lite test strips have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Freestyle Lite test strips.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3 (CPT code J7328). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the enrollee has not tried and failed the preferred step therapy (multi-
injection) device(s): Orthovisc OR Supartz FX. The Plan states there is no indication the Plan's preferred 
agent(s) would likely be: less effective, and/or cause adverse effects for the enrollee. 
 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 the medication. Our physician reviewer 
found there is no indication that the patient has tried and failed the required drug(s). Based on the medical 
records provided and the Medicare-approved major drug compendia there is no indication that the plan's 
required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gelsyn-3 (CPT code J7328).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for hospital discharge day management (99239) provided on December 20, 
2021. 
 
You asked the Plan to pay for hospital discharge day management. You say that you have provided records to 
support the service at issue. The Plan denied your request. The Plan says that rules for payment have not been 
met. 
 
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 99239 is "Hospital discharge day management; more than 30 minutes." 
 
We find that CPT code 99239 is supported in the medical record. Specifically, the available medical 
documentation specifies discharge day management spanning more than 30 minutes. Based on this information, 
we decided that Medicare rules for coverage of hospital discharge day management have been met. Therefore, 
we decided that the Plan has to pay for hospital discharge day management (99239) provided on December 20, 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
April 28, 2021 to May 1, 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 DRG was updated. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 205 (OTHER RESPIRATORY SYSTEM 
DIAGNOSES WITH MCC). 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 pay for the services. Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our physician 
reviewer found although the provider documented J96.01, reasonable support within the health record must be 
present for that diagnosis. DRG 206: OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC is 
the appropriate DRG.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from April 28, 2021 to May 1, 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 these services are medically necessary. The Plan 
denied your request. The Plan says that your nursing, medical management and rehabilitation needs do not 
require an interdisciplinary team approach to delivery of rehabilitation care. 
 
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. You 
are medically stable with no new and acute medical problems and do not need physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical conditions. There are no acute rehab nursing needs identified 
or documented in the record. At the current functional level as described above, you do not need intensive 
therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary 
approach in an IRF. You are not expected to make a significant functional recovery in the predicted 7-10 days 
with a baseline max assistance to total dependence. IRF admission is not medically necessary based on medical 
stability and lack of medical complexity, and lack of rehab nursing needs. Our physician reviewer found that 
your condition does not meet Medicare criteria for IRF 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 inpatient rehabilitation facility (IRF) admission and services.
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 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 Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and 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 Retacrit. Our reviewer says that the
services are not medically necessary. Our physician reviewer found Retacrit is FDA approved for the treatment
of anemia due to chronic kidney disease, including patients on dialysis and not on dialysis, to decrease the need
for red blood cell (RBC) transfusion. Treatment is initiated when Hb is <10 g/dL. This enrollee's most recent
hemoglobin is 10.9. The service is not reasonable or medically necessary and may not be safe and effective.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have
to pre-approve Retacrit.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that skilled services can be provided on an intermittent outpatient basis, in a 
long-term care facility, or at the home with home health care 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 services. Our reviewer says that 
SNF services are not medically reasonable and necessary. 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. 
Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve heart catheterization and ventriculography. 
 
You asked the Plan to pre-approve heart catheterization and ventriculography. 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 heart catheterization and 
ventriculography. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the enrollee has not undergone a nuclear stress test. 
The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, 
of the requested service. The elements of the coverage criteria are not satisfied. The requested service is not 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of heart catheterization and ventriculography have not been met. 
 
  
 Therefore, we decided that the Plan does not have to pre-approve heart catheterization and ventriculography.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (17250-59) provided on December 9, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed modifier is 
not supported. 
 
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.   
 
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 pay for the services Our reviewer says that the use 
of modifier -59 is not supported by the records provided. Our physician reviewer found that the procedure 
report describes debridement on right lateral leg, as well as silver nitrate reduction performed on the right 
lateral leg. The documentation does not support procedures were performed on separate wounds, and therefore 
would not be reported separately. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (17250-59) provided on December 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 27, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and it was 
determined these services were not urgent or emergent. 
 
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 laboratory services provided on January 27, 2022 
by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT, abdomen and pelvis; without contrast material 
(CPT code 74176) 
 
You asked the Plan to pre-approve the CT scan. You say that the enrollee needs this service has a history of 
cancer in their thyroid gland. The Plan denied your request. The Plan says they did not receive results of lab 
testing that confirms that the cells showed cancer or that the enrollee's disease has come back. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the CT scan. Our physician reviewer 
found there is no objective abnormalities from physical examination to justify imaging at this time. Beginning 
with blood tests first, changes in iron supplementation are more appropriate and decision based on the results to 
consider imaging could be made then if more suspect of having abdominal disease. Therefore, without 
sufficient support made for CT at this time, it will be considered 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 the CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve 
CT, abdomen and pelvis; without contrast material (CPT code 74176)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the provisional crown services identified with code D2799.
You asked the Plan to pre-approve the provisional crown services identified with code D2799. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the provisional crown services identified with code D2799.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supply allowance used with a therapeutic CGM device 
(K0553) provided December 24, 2021. 
 
You asked the Plan to pay for the therapeutic CGM device supplies. You say that the medical records provided 
will show proof of medical necessity. The Plan denied your request. The Plan says evidence of misrepresented 
services 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order, proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. Specifically, the Plan confirmed after outreach 
to the provider on the written order that this provider did not order this item. Therefore, the order is not a valid 
physician order. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for supply allowance used with a 
therapeutic CGM device (K0553) provided December 24, 2021.