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

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service October 27, 
2021. 
 You asked the Plan to pay for procedure code 71045. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 71045 is bundled into payment for 
code 36556. 
 
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 code 71045 
is a column II code to column I code 36556. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 71045 billed for date of service October 27, 
2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says that the denial of authorization for this service 
is correct, because inpatient level of care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our 
reviewer says that the enrollee meets the Medicare criteria for acute inpatient hospital care. Our physician 
reviewer found the enrollee presented to the emergency department with shortness of breath and tachycardia. 
The enrollee was evaluated and found to have rapid atrial fibrillation and congestive heart failure. The enrollee 
was treated with intravenous Lasix and admitted to telemetry, then placed on a Cardizem drip and evaluated by 
cardiology. The record shows that at the time of inpatient admission, the admitting physician would reasonably 
expect that the enrollee's necessary hospital care would span at least 2 midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pre-approve acute inpatient hospital care.  
 
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 treatment with Ilumya (J3245). 
 
You asked the Plan to pre-approve Ilumya. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been 
met. 
 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 Ilumya. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of Remicade, Inflectra, or Infliximab, and Stelara before they will approve the requested 
drug. The requested drug is a new start. The provided records do not indicate that the enrollee has tried and 
failed the Plan's preferred step-one alternatives. The record does not indicate that the enrollee has a 
contraindication to, or would have an adverse effect from, the Plan's preferred step-one alternatives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Ilumya (J3245).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the documentation does support a need for physical and/or occupational 
therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation 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 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements have not been met. 
 
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 Evenity. Our reviewer says that the 
requirements for coverage of Evenity have not been met. Our physician reviewer found the Plan requires a trial 
of Prolia or Reclast before they will approve the requested drug. The records do not show that the enrollee has 
tried either of these medications. The documentation does not support that Prolia or Reclast would likely be 
less effective or have adverse effects for the enrollee 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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new walker. 
 
You asked the Plan to pre-approve a new walker. You say that a new walker is medically necessary. The Plan 
denied your request. The Plan says your current equipment is less than five years old and there is no indication 
this equipment is damaged or inoperable. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. The file shows that you have walker. There is no indication your walker needs 
replacement. Therefore, we decided that the Plan does not have to pre-approve a new walker.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
to get to your medical appointments. The Plan denied your request. The Plan says once you have utilized the 
maximum number of transportation trips allowed per year, no additional trips can be approved. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 20 trips per year.  
 
  We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Benlysta. 
 
You asked the Plan to pre-approve Benlysta. The Plan denied your request. The Plan says the requested 
medication is reasonable or necessary at this time.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Benlysta. Our reviewer says that the 
elements of the coverage criteria are not satisfied, and the requested service cannot be recommended. Our 
physician reviewer found that the record provided does not indicate that the enrollee is receiving standard 
therapy. The FDA has not stated that the requested drug is indicated for the enrollee's condition. The Medicare 
approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's 
clinical situation. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Benlysta have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Benlysta.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery for the 
enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
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 the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this device is experimental at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vertiflex Superion device placement surgery for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 9, 
2021. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 9, 
2021.
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 the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the request for a home mechanical ventilator set in Intelligent Volume Assured 
Pressure Support (iVAPS) mode with Auto-EPAP (AE) that could be delivered by bilateral positive airway 
pressure (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 the ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found you have 
severe chronic obstructive pulmonary disease and obstructive sleep apnea. You were recently hospitalized 
acute respiratory failure requiring intubation, with a PaCO2 greater than 100. You responded to BiPAP after extubation. However, you have been intolerance of continuous positive airway pressure (CPAP) and BiPAP at 
home because of mask interface issues, despite repeated attempts to address this. A home ventilator will not 
solve the problem of mask intolerance. BiPAP is the appropriate treatment. Medicare does not cover a home 
ventilator when used as BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a portable ventilator.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram (ECG) services provided on July 22, 
2021. 
 
You asked the Plan to pay for the services provided. You say that the code should be considered for separate 
reimbursement. The Plan denied your request. The Plan says the claim processed correctly. 
 
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.   
 
In this case, the CPT Code Manual definition of code 93042 is Rhythm ECG, 1-3 leads; interpretation and 
report only. We find that CPT code 93042 is not supported in the medical record.  The medical records provided do not include an interpretation and report of a rhythm electrocardiogram. The 
records do not show that the service billed with the -59 modifier was a distinct procedural service. Based on 
this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not 
been met. Therefore, we decided that the Plan does not have to pay for the electrocardiogram (ECG) services 
provided on July 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the breast reduction surgery (19318). 
 
You asked the Plan to pre-approve the breast reduction surgery. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the request is not medically necessary because the 
records show that the enrollee's Schnur 
recommended tissue removal is 950-1000g, but the provider wants to only remove a small amount of breast 
tissue consistent with a cosmetic not reconstructive procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable.   
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the breast reduction surgery have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the breast reduction surgery (19318).
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 patient is ready for discharge from the hospital 
and SNF is needed. The Plan denied your request. The Plan says the patient is currently medically unstable and 
not able to participate in therapy. At this time, continuation of medical management in the acute hospital is 
beneficial, so SNF placement isn't appropriate right now. If at a later date the patient is able to participate in 
therapy and his postural hypotension is controlled, SNF may be appropriate at that time.  
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 patient has stabilized medically and is 
ready for discharge from the hospital. The patient does not require skilled nursing and/or skilled therapy 
services on a daily basis. He is medically stable and can receive further rehab services at a lower level of care. 
Although further rehab services would be appropriate to improve function, as a practical matter, the 
intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The patient 
does not have any parental medication; complex wound care or nutrition given via a feeding tube.  He is 
medically stable without any acute exacerbations of chronic medical problems.  His physical function is at or 
near his baseline and he can receive services at a lower level of care.  Admission to a SNF for inpatient skilled 
rehab services 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 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 pay for lodging and gas expenses for transplant from September 17, 
2021, to October 11, 2021. 
 
You asked the Plan to pay for these expenses. You say that these costs should be covered by the Plan. The Plan 
denied your request. The Plan says you had other insurance as primary and this Plan as secondary.  To process 
your request, the Plan needs an Explanation of Benefits from the primary insurance carrier.  
 The Plan has tried to obtain the Explanation of Benefits from the other insurance, however the primary insurer 
stated that they don't have a claim on file from you. This Plan as secondary insurer cannot process your request 
until its is submitted to and addressed by the primary insurer, and they submit an explanation of benefits to 
show the result.  
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. The Plan has met its obligation with 
regards to coordination of benefits. Specifically, the Plan has contacted both you and the primary insurer to 
explain the process for getting the claims reviewed in the proper order. As the secondary insurer, the Plan 
cannot be held responsible for these services until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for lodging and gas expenses for transplant from 
September 17, 2021, to October 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on November 8, 2021, 
and the eyeglasses (V2020, V2100, V2745) purchased on November 17, 2021. 
 You asked the Plan to pay for the routine vision services. You say that you have had coverage for these 
services in previous years and you feel you should be reimbursed for these services. The Plan denied your 
request. The Plan says routine eyewear and vision exams for the purpose of prescribing routine eyewear are not 
covered by Original Medicare. Your routine vision coverage ended in 2019, and your Plan at the time of 
services did not include a mandatory or an optional supplemental benefit to cover these services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for the eye refraction (92015) provided on November 8, 2021, and 
the eyeglasses (V2020, V2100, V2745) purchased on November 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99205), panoramic x-ray (70355), and oral 
device/appliance used to reduce upper airway collapsibility (E0486) provided on September 27, 2021. 
 
You asked the Plan to pay for the dental services. You say that you had a CPAP machine on recall. You say 
that you waited 4 months and have not heard anything. You also say that you decided to go with a mouth guard 
for obstructive sleep apnea. The Plan denied your request. The Plan says the provider in this case has opted out 
of Medicare. The Plan also says that payment cannot be made for services rendered by a provider that has 
opted out of Medicare. 

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office 
visit (99205), panoramic x-ray (70355), and oral device/appliance used to reduce upper airway collapsibility 
(E0486) provided on September 27, 2021.