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

 
We decided that the Plan does not have to pay for mass spectrometry testing provided on September 28, 2021. 
 
You asked the Plan to pay for mass spectrometry. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of payment for this test is correct, because this test is not 
separately payable when performed as specimen validity testing. 
 
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.   
 
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, the documentation does not support that this validity testing was a separate and distinct 
procedure from the drug testing covered on this claim. 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 mass spectrometry testing provided on September 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that this should be paid for. The Plan 
denied your request. The Plan says this is not a covered benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an infliximab injection provided from 
November 10, 2021, to December 22, 2021. 
 
You asked the Plan to waive the coinsurance for an infliximab injection. You say that you cannot afford to pay 
20% of the cost every time you get this injection. You also say that if you were aware of the cost, you would 
not have gotten the injection. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
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 20% 
coinsurance for Part B drugs.  
 
 You have been asked to pay a total of $948.72, which is 20% coinsurance for infliximab injections received on 
November 10, 2021, November 24, 2021, and December 22, 2021. 
 
Date of Service Allowed Amount 20% Coinsurance 
November 10, 2021 $1,304.49 $260.90 
November 10, 2021 $276.71 $55.34 
November 24, 2021 $1,304.49 $260.90 
November 24, 2021 $276.71 $55.34 
December 22, 2021 $1,264.96 $252.99 
December 22, 2021 $316.24 $63.25 
Total  $948.72 
 
An infliximab injection falls within the Medicare Part B Prescriptions Drugs 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 coinsurance for an infliximab injection provided from November 10, 2021, to 
December 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You did not provide a specific argument with your 
appeal request. The Plan denied your request. The Plan says there is no advantage to moving the patient from 
their current acute care hospital to a LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient is presently receiving needed services in the short-term acute care setting. 
Continued care in the short-term acute care hospital is appropriate (and endorsed by the health plan) until the 
patient is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a sub-acute 
rehabilitation facility or a skilled nursing facility. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
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 SNF is needed so that the patient can receive 
appropriate therapies. The Plan denied your request. The Plan says the patient can be managed at a lower level 
of 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 daily 
skilled services are not necessary. Our physician reviewer found the patient has no documented skilled nursing 
needs.  While they do have skilled therapy needs, there is no documentation showing that these services are 
required on an inpatient basis in a SNF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the RomTech Adaptive Rehabilitation Device and 
AccuAngle device. 
 
You asked the Plan to pre-approve the RomTech Adaptive Rehabilitation Device and AccuAngle device. You 
say that you are scheduled for surgery next week and you are in your 70s.  You said that you need these items 
for your recovery and to improve your quality of life. The Plan denied your request. The Plan says these items 
are not medically necessary and not more appropriate than standard items/treatment. 
 
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 RomTech Adaptive Rehabilitation 
Device and AccuAngle device. Our reviewer says that the requested items are not considered medically 
reasonable and necessary in this case. Our physician reviewer found these requested items do not meet 
Medicare's medical necessity criteria. 
 
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 RomTech Adaptive Rehabilitation Device and AccuAngle device have not been met. Therefore, we decided that the Plan does not have to pre-approve the RomTech Adaptive 
Rehabilitation Device and AccuAngle device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a pembrolizumab injection provided on 
November 22, 2021. 
 
You asked the Plan to waive the coinsurance for a pembrolizumab injection. You say that your wife was never 
at this hospital. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay 20% coinsurance for in-network Part B drug.  
 
The medical records show the enrollee received a pembrolizumab injection on November 22, 2021. You have 
been asked to pay $1,443.90, which is 20% of the allowed amount for a pembrolizumab injection ($7,219.53 allowed amount x 20% coinsurance = $1,443.90). A pembrolizumab injection falls within the Medicare Part B 
Prescription Drug benefit category. This means that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a 
pembrolizumab injection provided on November 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic laboratory services provided on September 27, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services in question were clearly 
medically necessary, as evidenced by the enclosed requisition form from the enrollee's treating physician. The 
Plan denied your request. The Plan says enrollees must receive their medical services from an in-network 
provider with the exception being urgent or emergent services. Non-emergent services with non-contracted 
providers require prior authorization before services being rendered. 
 
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 diagnostic laboratory services provided on 
September 27, 2021 by an out-of-network (OON) provider.
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 inpatient rehabilitation is medically necessary for 
this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The 
enrollee's needs can be met in a less intensive setting. 
 
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 that 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. 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 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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve positioning cushions. 
 
You asked the Plan to pre-approve positioning cushions. You say that a positioning cushion is medically 
necessary. The Plan denied your request. The Plan says a positioning cushion is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. 
This item is available to the 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 positioning cushions.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy to be provided by a 
participating provider. 
 
You asked the Plan to pre-approve physical therapy. You say that additional physical therapy is medically 
necessary. The Plan denied your request. The Plan says two additional sessions have been approved. The Plan 
says that they have denied seven additional sessions. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the member was having minimal deficits in functional strength and 
activity tolerance that result in difficulty performing functional activities since beginning physical therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional physical therapy to be provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dry pressure mattress (E0184). 
 
You asked the Plan to pre-approve the dry pressure mattress. You say that you would like reconsideration 
because the requested mattress is medically necessary. The Plan denied your request. The Plan says the criteria 
for a dry pressure mattress 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 the dry pressure mattress. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support that this enrollee is completely immobile, has 
limited mobility with an inability to make changes in body position significant enough to alleviate pressure, or 
has any stage pressure ulcer on the trunk or pelvis. 
 
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 dry pressure mattress have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the dry pressure mattress (E0184).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a panniculectomy procedure. 
 
You asked the Plan to pre-approve the panniculectomy. You say that you will benefit from panniculectomy. 
The Plan denied your request. The Plan says this request does not meet Medicare criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that when a panniculectomy is performed to alleviate such 
complicating factors as inability to walk normally, chronic pain, ulceration created by the abdominal skin fold, 
or intertrigal dermatitis, and the above symptoms have been present for at least three months and are refractory 
to usual standard medical therapy, such surgery may be considered reconstructive and therefore coverable. 
 
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 panniculectomy. Our reviewer says 
that the requested panniculectomy is not medically necessary. Our physician reviewer found based on the 
medical records provided there is no documentation that the requested panniculectomy is being requested 
to alleviate such complicating factors as inability to walk normally, chronic pain, ulceration created by the 
abdominal skin fold, or intertrigal dermatitis, and the above symptoms have been present for at least three 
months and are refractory to usual standard medical therapy.  
 
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 panniculectomy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a panniculectomy procedure.
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 enrollee needs inpatient rehabilitation before he 
can safely return home. The Plan denied your request. The Plan says the criteria for admission to an IRF are not 
met. The enrollee can safely receive the services they need in an alternate setting. 
 
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 that 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. 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 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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional overnight medical services (99053) provided on 
July 11, 2021. 
 
You asked the Plan to pay for additional overnight medical services. You say that you have provided records to 
support the level of service. The Plan denied your request. The Plan says 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. 
 
Per the Physician Fee Schedule, CPT code 99053 has a status indicator of B. This means that the payment for 
99053 is always bundled into the payment for another service or procedure. Based on this information, we 
decided that Medicare rules for coverage of additional overnight medical services have not been met. 
Therefore, we decided that the Plan does not have to pay for additional overnight medical services (99053) 
provided on July 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that a total electric hospital bed is 
medically necessary. The Plan denied your request. The Plan says a total electric hospital bed is not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on June 29, 
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 claim does not meet coding standards. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
laboratory services provided to the enrollee on June 29, 2021.