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

 We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466), for the enrollee. 
 
You asked the Plan to pre-approve the home ventilator. You say that this is to be used for the treatment of 
chronic respiratory failure (CRF) related to chronic obstructive pulmonary disease (COPD) and chronic 
narcotic use. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in 
average volume-assured pressure support (AVAPS) mode that could be delivered by bilevel 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 home ventilator. Our physician reviewer found the record indicates that the enrollee has chronic hypercarbic respiratory failure from chronic 
obstructive pulmonary disease. The record indicates that VAPS mode has been ordered. The provided primary 
source documentation does not contain sufficient detailed information in the medical record to justify the 
treatment selected. The enrollee could be treated with a BiPAP machine with AVAPS capability. The record 
does not indicate that this was tried and failed or contraindicated. The plan has indicated such a device is 
covered. 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 the home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided from February 3, 2021, to February 8, 2021.
You asked the Plan to pay for the inpatient services. The Plan denied your request. The Plan says the billed DRG is not supported.
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 A41.9. We asked our coding 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 inpatient services. Our reviewer says that the use of diagnosis code A41.9 is not supported by the records provided. Our physician reviewer found that sepsis is documented as secondary to intra-abdominal abscess, however, documentation does not support the diagnosis of sepsis due to no consistent clinical manifestations of any of the 3 stages of sepsis (sepsis - fever, increase heart rate > 90, increased breathing rate > 20 or probable or confirmed infection), as well as increase in SOFA score of 2 points or more. We looked at this coder'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 the inpatient services provided from February 3, 2021, to February 8, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for SNF care have not been met. 
 
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 member has stabilized medically and has 
been receiving skilled rehab services in an inpatient rehabilitation facility (IRF). The member no longer 
requires daily skilled nursing and/or skilled therapy services. She could benefit from continued intermittent 
services at a lower level of care. Although the member made slow progress with therapy, her functional 
improvement has plateaued, there is no indication that transfer to a skilled nursing facility is required. She can 
continue to receive skilled rehab services at the current IRF or be stepped down to a lower level of care.  
There are no services offered at a SNF that are not offered at an inpatient rehab facility. 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 admission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the 3D rendering services provided on March 15, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the need for 3D rendering must be documented in the 
medical record for coverage to be considered. 
 
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 
requested 3D rendering services are not medically reasonable and necessary. Our physician reviewer found that 
there is no documentation in the report of the magnetic resonance cholangiopancreatography (MRCP) 
describing the need for 3D rendering. In order to qualify for reimbursement, the necessity for 3D rendering 
must be explicitly mentioned in the report. 
 
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 3D rendering services provided on March 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant 360 testing provided on June 9, 2021. 
 
You asked the Plan to pay for the Guardant 360 testing. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the CPT codes billed for the Guardant 360 testing are not supported in the medical record. 
Specifically, this service should be billed with a single code. Review of the file shows that these services were 
billed with 19 separate codes. This means these services were billed incorrectly. Based on this information, we decided that Medicare rules for coverage of the Guardant 360 testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the Guardant 360 testing provided on 
June 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 18, 2021, by an OON 
provider. 
 
You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
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 genetic testing provided on May 18, 2021, by 
an OON provider.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to cover the ultrasound, pelvic (non-obstetric), real time with image 
documentation; limited or follow-up (76857) provided June 25, 2021. 
 
You asked the Plan to cover the non-obstetric pelvic ultrasound. You say that this service should be covered. 
The Plan denied your request. The Plan says that this procedure is not paid separately. 
 
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. In this case there is no evidence provided by the Plan that this service is included 
in another service already adjudicated by the Plan. Therefore, we decided that the Plan has to cover the 
ultrasound, pelvic (non-obstetric), real time with image documentation; limited or follow-up (76857) provided 
June 25, 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 pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. 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 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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does 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. 
There is not a reasonable expectation that the 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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
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 you do not meet criteria for SNF 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 daily skilled services are not necessary. Our physician reviewer found that your 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for medical services provided outside of the United 
States of America from July 2, 2020, through December 23, 2020. 
 
You asked the Plan to reimburse you for medical services provided outside of the United States of America. 
You say that the severity of your illness needed immediate medical attention and you were too sick to travel 
back to the United States. You say if you did not receive these medical services, it could have resulted in your 
death. The Plan denied your request. The Plan says worldwide emergency/urgent care coverage is limited  
to services that would be classified as emergency, urgently needed, or post stabilization care had they been  
provided in the United States. Not only does the EOC not cover non-emergent care provided outside of the US 
and its territories, the member was no longer eligible for this health Plan after being outside of the service area 
over 6 months. 
 Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
We looked at the file, the Medicare rules and the Plan's rules. Based on this information, we decided that rules 
for coverage of medical services provided outside of the United States of America have not been met. 
Therefore, we decided that the Plan does not have to reimburse you for medical services provided outside of 
the United States of America from July 2, 2020, through December 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the $30 copayment charged for specialist services provided on 
August 5, 2021. 
 
You asked the Plan to waive this copayment. You say that this copayment should be $5. The Plan denied your 
request. The Plan says this copayment was charged based on the services received. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $30 
copayment for specialist services. You have been asked to pay $30 copayment for this copayment. this 
copayment falls within the specialist services benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the $30 
copayment charged for specialist services provided on August 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Erbitux, Fluoracil, Leucovorin Calcium, Irinotecan, 
Atropine Sulfate, Dexamethasone, Promethazine, Diphenhydramine for the enrollee. 
 
You asked the Plan to pre-approve the drugs. You say that this is medically necessary. The Plan denied your 
request. The Plan says the documentation does not support that the member has a diagnosis of metastatic 
colorectal cancer that expresses verified wild-type (normal) Kirsten rat sarcoma virus (KRAS)/ NRAS. 
 
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 the drugs. Our reviewer says that the 
requested drugs are not medically reasonable or necessary. Our physician reviewer found the combination of 
FOLFIRI cetuximab (Erbitux) is supported for patients whose tumors are NRAS/KRAS wild type. There are no 
results provided. This is not safe and effective without results showing that this combination of drugs is 
effective for this type of tumor. 
 
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 drugs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Erbitux, Fluoracil, Leucovorin Calcium, Irinotecan, Atropine Sulfate, Dexamethasone, 
Promethazine, Diphenhydramine for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing rendered on May 17, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the CxBladder testing is non-covered. 
 
We looked at the file and Medicare rules. The test at issue is CxBladder. This test is not covered by Medicare. 
Therefore, we decided that the Plan does not have to pay for the CxBladder testing rendered on May 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller, including all related electronics 
and mounting hardware, upgrade provided at initial issue (CPT code E2377), harness for upgrade to 
expandable controller, including all fasteners, connectors and mounting hardware (CPT code E2313) and 
electronic connection between wheelchair controller and two or more power seating system motors, including 
all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware 
(CPT code E2311) for the enrollee. 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. The upgraded electronics (expandable 
controller, harness and electronic connector to 2 power options) are not medically necessary. They are 
necessary when there is a medical need to control power options though the joystick. The notes do not show a 
medical need to control the power options through the joystick. The power options can be controlled using their 
own switches. These switches can be made any size without asking for a separate request. They can be made 
from any material without asking for a separate request. All of this can be done without the need to use the 
joystick to control the power features. Therefore, we decided that the Plan does not have to pre-approve 
expandable controller, including all related electronics and mounting hardware, upgrade provided at initial 
issue (CPT code E2377), harness for upgrade to expandable controller, including all fasteners, connectors and 
mounting hardware (CPT code E2313) and electronic connection between wheelchair controller and two or 
more power seating system motors, including all related electronics, indicator feature, mechanical function 
selection switch, and fixed mounting hardware (CPT code E2311) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve power seat elevation system (CPT code E2300). 
 
You asked the Plan to pre-approve the power seat elevation system. You say that you are a polio patient and are 
dependent on power chair mobility. You state you need this for safety reasons as this would allow you to reach 
a microwave and a hot stove or medicine cabinet, clothes, kitchen items, slide the power seat to bed and to 
transfer from chair to doctor table. The Plan denied your request. The Plan says Medicare considers this to be 
not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 The rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered 
because they are not primarily medical in nature. The item at issue in this appeal does not serve a purpose that 
is primarily medical in nature. This item is available to the general public and would be helpful even to those 
who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve power seat 
elevation system (CPT code E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the porcelain crowns (D6740 x 2) and porcelain pontics 
(D6245 x 4) provided on June 3, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were told the implant and bridge would be 
covered. You say that you paid $5,300 as a down payment. You also say that the office kept your money. The 
Plan denied your request. The Plan says porcelain retainer crowns are not listed as covered services. The Plan 
says porcelain pontics are not listed as covered services either. 
 
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 porcelain retainer crowns and 
porcelain pontics are not among those covered under this benefit. Additionally, the file shows that you were 
advised prior to receiving these services that they would not be covered and given a discounted rate by the 
dentist. Therefore, we decided that the Plan does not have to pay for the porcelain crowns (D6740 x 2) and 
porcelain pontics (D6245 x 4) provided on June 3, 2021.