Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for IRF admission and services provided from February 2, 2022, 
to February 16, 2022. 
 
You asked the Plan to pay for IRF care. The Plan denied your request. The Plan says based on Medicare 
guidelines, the IRF services do not meet the requirements for approval. 
 
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 pay for IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for weakness and a urinary tract infection. The enrollees medical problems are stable. There are 
no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pay for IRF admission and services provided from February 2, 2022, to February 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for over-the-counter (OTC) home COVID-19 self-tests 
purchased on February 20, 2022. 
 
You asked the Plan to pay for OTC COVID-19 tests. You say that these tests should be reimbursed as they 
were purchased after January 15, 2022. The Plan denied your request. The Plan says these items were 
purchased before the date they were eligible for reimbursement. The Plan must follow Medicare rules. Medicare rules say that Original Medicare will cover up to eight over-
the-counter COVID-19 tests each calendar month under Part B. If you are in a Medicare Advantage plan, the 
tests covered under this initiative will be covered outside of your existing plans coverage. Enrollees cannot 
submit a claim for these tests to Medicare or their MA plan (unless covered by a supplemental benefit) for 
reimbursement under this initiative. The participating provider would bill Medicare directly for reimbursement 
of the tests provided to the enrollee. 
 
We looked at the file and Medicare rules. Although Medicare Advantage plans were encouraged to offer 
coverage of OTC COVID-19 tests as a supplemental benefit starting January 15, 2022, your Plan did not opt to 
provide this optional coverage. Official coverage of COVID-19 home tests through Original Medicare began 
on April 4, 2022, which is after the date of purchase in this case. Based on this information, we decided that 
Medicare rules for coverage of OTC COVID-19 tests have not been met. Therefore, we decided that the Plan 
does not have to pay for over-the-counter (OTC) home COVID-19 self-tests purchased on February 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device. 
 
You asked the Plan to pre-approve pneumatic compression device. You say that you have had lymphedema for 
over 2 years and other treatment have not worked. The Plan denied your request. The Plan says the denial of 
authorization for this device is correct, because the record does not show that you have a diagnosis of chronic 
and severe lymphedema. 
 
The Plan follows Medicare rules. Medicare rules state that a pneumatic compression device (PCD) is only 
covered if certain 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 pneumatic compression device. Our 
reviewer says that you do not meet the Medicare criteria for the requested pneumatic compression device. Our 
physician reviewer found the records provided do not clearly show failure of adequate compression and regular 
exercise as required by the rules. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pneumatic compression device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a pneumatic compression device.
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 continuation of SNF care is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for continued SNF 
care. 
 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 
enrollee does not meet criteria for continued SNF care. Our physician reviewer found at the time of admission, 
the member required skilled rehab services to improve function due to weakness and deconditioning.  There 
were no skilled nursing needs. As of August 19, 2022, the member did not require any skilled nursing or rehab 
services on a daily basis. She was not expected to make measurable gains within a reasonable and predictable 
period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living. The 
member did not require skilled therapy to establish a safe and effective maintenance program. As a practical 
matter, the member did not require any skilled services on an inpatient basis, at a SNF level of care as of 
August 19, 2022. 
 
The member did not have any parental medications, complex wound care or nutrition given via a feeding tube. 
The member received skilled care and improved; however, her functional improvement had plateaued by 
August 18, 2022, and she did not require any further inpatient skilled rehab services. The members function 
was at or near her new baseline level of function and she could be discharged to a lower level of care for 
further services.  As of August 19, 2022, the member required custodial 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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 continuation of SNF care is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for continued SNF 
care. 
 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 
enrollee does not meet criteria for continued SNF care. Our physician reviewer found based on the 
documentation provided, the enrollee no longer qualifies for SNF coverage. The enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee 
appears to be functioning at/near her baseline. 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. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on May 11, 2021. 
 
You asked the Plan to pay for the medical services. You say that the patient gave you incorrect insurance 
information.  You said that you filed this claim as soon as you got corrected information. The Plan denied your 
request. The Plan says you did not timely file this claim. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the medical services was not filed until May 13, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for medical services provided on May 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation. 
 
You asked the Plan to pre-approve radiofrequency ablation. 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 radiofrequency ablation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered an experimental/ investigational procedure whose role in the 
treatment of knee osteoarthritis is still being evaluated. Therefore, at this point, the request is deemed not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99291 on December 17, 2021, 99292 on December 10, 
18, and 19, 2021, 31645 on December 17, 2021, and 31624 on December 17, 2021. 
 
You asked the Plan to pay for codes 99291, 99292, 31645, and 31624. You say that the records support these 
codes. The Plan denied your request. The Plan says these codes are not supported. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. The definition of 99292 is critical care, evaluation 
and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in 
addition to code for primary service). The definition of 31645 is bronchoscopy, rigid or flexible, including 
fluoroscopic guidance, when performed; with therapeutic aspiration of tracheobronchial tree, initial. The 
definition of 31624 is bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with 
bronchial alveolar lavage.  
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 codes 99291, 99292, 31645, and 31624. Our reviewer says 
that the billed codes are not supported. Our reviewer found the procedure report for December 17, 2021, does 
not have time service performed documented and therefore code 99291 cannot be verified. Code 99292 is an 
add-on code that was not billed with a primary procedure on December 10, 18, and 19, 2021. The procedure 
report also documents the date of operation for codes 31645 and 31624 as December 18, 2021, but these 
services were billed with the date of service December 17, 2021. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 99291, 99292, 31645, and 31624 have not been met. Therefore, we 
decided that the Plan does not have to pay for code 99291 on December 17, 2021, 99292 on December 10, 18, 
and 19, 2021, 31645 on December 17, 2021, and 31624 on December 17, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on August 26, 2021. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary and 
provided in good faith. The Plan denied your request. The Plan says it is not responsible for this bill because 
the patient was enrolled in hospice on the date of service in question. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided on August 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a foot insert/molded arch support provided on April 4, 2022, 
by an out-of-network provider. 
 
You asked the Plan to pay for the foot insert. You say that you were told that because you are a diabetic the 
foot insert would be covered. The Plan denied your request. The Plan says the provider is out-of-network and 
there was no referring provider. 
 
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 a foot insert/molded arch support provided on 
April 4, 2022, by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vectibix. 
 
You asked the Plan to pre-approve Vectibix. 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 Vectibix. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, the record indicates that the 
enrollee has a diagnosis of adenocarcinoma of the duodenum. The Food and Drug Administration has not 
stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug 
compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation. No literature from Medicare approved cancer journals were submitted for review. The elements of the 
coverage criteria are not satisfied. The requested service cannot be 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 Vectibix have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vectibix.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a therapeutic procedure (97110) provided on February 7, 
2022, by an out-of-network provider. 
 
You asked the Plan to pay for the therapeutic procedure. The Plan denied your request. The Plan says the 
enrollee received care from an out-of-network provider and there is no record of an approved referral being 
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 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 a therapeutic procedure (97110) provided on 
February 7, 2022, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care, and nail debridement 
provided on March 22, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care, and nail debridement. You say that the patient is 
a resident in a nursing home and has an authorization on file for all care at the facility including consultations. 
The Plan denied your request. The Plan says services from non-participating providers are not covered unless 
preauthorized. 
 
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 subsequent nursing facility care, and nail 
debridement provided on March 22, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 82435, 84132, 84295, 83721, 84480, 82465, 
and 84478 billed for date of service November 24, 2021. 
 
You asked the Plan to pay for procedure codes 82435, 84132, 84295, 83721, 84480, 82465, and 84478. The 
Plan denied your request. The Plan says payment for these codes is bundled. 
 
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 
82435, 84132, and 84295 are column II code to column I code 80051. We have also confirmed that code 83721 
is a column II code to column I code 80051. This claim has not been billed with an appropriate modifier to 
bypass the edit. 
 
We have also confirmed that codes 82465 and 844788 are column II codes to column I code 80061, and that 
code 84480 is a column II code to column I code 84481, with a modifier indicator of 0. The column II code is 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 82435, 84132, 84295, 83721, 84480, 82465, and 
84478 billed for date of service November 24, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Abilify Maintena. 
 
You asked the Plan to pre-approve Abilify Maintena. You say that the medication is necessary. The Plan 
denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate 
pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for 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 Abilify Maintena.  
 
Benefits for Abilify Maintena 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paring or cutting of benign hyperkeratotic lesion 
provided and the debridement of nails on March 1, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the paring or cutting of benign hyperkeratotic lesion provided and the 
debridement of nails. You say that the patient is a resident in a nursing home and has an authorization on file 
for all care at the facility including consultations. The Plan denied your request. The Plan says services from 
non-participating providers are not covered unless preauthorized. 
 
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 paring or cutting of benign hyperkeratotic 
lesion provided and the debridement of nails on March 1, 2022, by an out-of-network (OON) provider.