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

 
We decided that the Plan does not have to pay for intermittent urinary catheters; straight tip (A4351) provided 
on July 27, 2022. 
 
You asked the Plan to pay for intermittent urinary catheters. You say that you are requesting reconsideration 
stating Medicare guidelines allow 200 units of the urinary catheter per month and you have shipped 180, which 
is within the limits. The Plan denied your request. The Plan says since this supply is allowed 200 units per 
month, additional units are not warranted since 600 units have been paid within 74 days. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The LCD confirms the maximum quantity of supplies available are 
200 units per month. The records show that you have received 600 urinary catheters in 74 days, therefore, you 
have exhausted your maximum benefit. Based on this information, we decided that Medicare rules for coverage 
of intermittent urinary catheter have not been met. Therefore, we decided that the Plan does not have to pay for 
intermittent urinary catheters; straight tip (A4351) provided on July 27, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 
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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee does not have skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not 
require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 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 SNF care.
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 these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says there was no three consecutive day inpatient hospital stay prior the SNF admission. 
 
The Plan must follow Medicare rules. The rules say that, in order to receive covered post hospital SNF 
services, the beneficiary must have a medically necessary inpatient hospital stay for at least three consecutive 
calendar days, not counting the day of discharge. 
 
We looked at the file and Medicare rules. The file shows that the enrollee did not have an inpatient hospital 
stay of at least three consecutive calendar days. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve 
skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xospata. 
 
You asked the Plan to pre-approve Xospata. You say that this drug is medically necessary for the enrollees 
condition. The Plan denied your request. The Plan says this drug is not among those covered under the 
enrollee's medical benefit. 
 
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 Xospata.  
 
Benefits for Xospata 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve advanced knee and advanced foot. 
 You asked the Plan to pre-approve the services. You say that this will be appropriate for the enrollee to begin a 
new normal life as an above knee amputee. The Plan denied your request. The Plan says the requested K3 knee 
and foot exceed the enrollee's need and does not meet the Medicare criteria of reasonable and necessary. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the requested items exceed your medical needs. The physician documentation notes that you need a 
wheelchair. The treating physician documentation does not support that you are a K3 ambulator. 
 
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 pre-approve advanced knee and advanced foot.
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 if the enrollee goes to a lower level of care, he will 
not be able to regain maximum function to return home. The Plan denied your request. The Plan says an IRF 
admission 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of impacted tooth partially bony (D7230) 
and therapeutic parenteral drugs, two or more administrations (D9612). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says these services are not covered by the Plan's dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
removal of impacted tooth partially bony (D7230) and therapeutic parenteral drugs, two or more 
administrations (D9612).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 6, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you feel the claim should be reimbursed 
because Medicare pays CPT code 81521 when billed for MammaPrint. The Plan denied your request. The Plan 
says the services rendered are not Medicare-covered services and the provider is out-of-network for the 
enrollee. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on May 6, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy services. 
 
You asked the Plan to pre-approve proton beam therapy services. You say that this procedure is medically 
necessary for the enrollee's cancer. The Plan denied your request. The Plan says the requested proton beam 
therapy is not covered for prostate cancer. 
 
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 proton beam therapy services. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee is a 66-year-old male with high-risk prostate cancer. In 
this case, there is insufficient prospective, long-term clinical data available to determine whether or not proton 
beam radiation therapy for prostate cancer is superior, inferior or equivalent to external beam radiation therapy, 
intensity-modulated radiation therapy (IMRT), or brachytherapy with regards to safety and efficacy. Recent 
data shows no significant differences in late (years one, two, and three) patient-reported toxicity outcomes 
between proton beam therapy and IMRT. The most recent American Urological Association and National 
Comprehensive Cancer Network guidelines state that proton beam therapy offers no clinical advantage over other forms of definitive treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve proton beam therapy services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from sub-acute 
rehabilitation placement upon discharge to improve balance, ambulation and stair negotiation skills prior to 
returning home. The Plan denied your request. The Plan says the services are 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 enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollee's care needs can be met 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine PCR (polymerase chain reaction) panel (87481, 
87641, 87651, 87653, and 87798) billed for date of service July 20, 2022. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this panel was not billed in 
accordance with Medicare guidelines. 
 The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of infectious disease pathogen identification testing have not been met. Specifically, the records show 
that a single panel was ordered and performed, but this service was billed by reporting individual components. 
Therefore, we decided that the Plan does not have to pay for the urine PCR (polymerase chain reaction) panel 
(87481, 87641, 87651, 87653, and 87798) billed for date of service July 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular profile testing provided on February 17, 2022. 
 
You asked the Plan to pay for the molecular profile testing. You say that this testing is considered medically 
necessary and is covered by Medicare. The Plan denied your request. The Plan says there is not sufficient 
evidence to support the medical necessity of this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing must be ordered by the treating 
provider, with evidence in the medical record of the intent for said testing. In addition, the rules say that 
providers must submit sufficient information to support that Medicare criteria are met.   
 
We looked at the file and Medicare rules. We find that there is not sufficient information in the file to 
determine the panel that the treating physician intended to be performed. The order form submitted has two panels listed with neither being checked by the provider. The lab report also does not identify the specific panel 
that was provided. While the progress note does indicate that molecular profiling was intended, the note does 
not indicate which specific test is to be ordered. Without this information, it cannot be determined whether the 
panel has been reviewed and found to be covered by Medicare. Therefore, we decided that the Plan does not 
have to pay for the molecular profile testing provided on February 17, 2022.
Appeal type: Step-Therapy
Decision: Favorable

 
We decided that the Plan has to pre-approve Vyvgart. 
 
You asked the Plan to pre-approve Vyvgart. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has 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 Vyvgart. Our reviewer says that the 
services are medically necessary. Our physician reviewer found the Plan requires a trial of drug two 
immunosuppressants (e.g., azathioprine, cyclosporine, methotrexate, mycophenolate, tacrolimus) before they 
will approve the requested drug. In this case, the patient has not tried and failed the required drugs. The 
documentation indicates that the plans required drugs would likely be less effective and/or likely have adverse 
effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vyvgart have been met. Therefore, we decided that the Plan has to pre-approve 
Vyvgart.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided March 20, 2022 to April 18, 
2022. 
 
You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date result in no payment being made for the episode of care.  
 
In this case, the admit date is January 19, 2022 per the NOA. The claim was not submitted with a valid "from" 
date. Therefore, we decided that the Plan does not have to pay for home health services provided March 20, 
2022 to April 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the repair of abdomen using abdominal lining graft coded 
49905 provided on February 7, 2022. 
 
You asked the Plan to pay for the repair of abdomen using abdominal lining graft. You say that you would like 
this claim reprocessed as the services were medically necessary. The Plan denied your request. The Plan says 
this is an add-on code that was reported without a primary procedure. 
 
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 the 
repair of abdomen using abdominal lining graft is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, 
we decided that the Plan does not have to pay for the repair of abdomen using abdominal lining graft coded 
49905 provided on February 7, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 27, 2022. 
 
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 separately payable. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment 
may be made only if the physician interprets an abnormal smear for hospital inpatient. 
 
We looked at the file and Medicare rules. Billed procedure code 85060 has a PC/TC indicator of 8. The file 
shows that the services were not performed for a hospital inpatient. Therefore, we decided that the Plan does 
not have to pay for the laboratory services rendered on June 27, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided May 19, 2022, to June 17, 
2022. 
 
You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied. 
 
The Plan follows Medicare rules. The rules say that the claim and the NOA must contain certain data elements. 
 
In this case, the NOA was submitted with a from date of January 19, 2022. The claim was submitted with an 
admission date of December 20, 2021. As the claim was submitted with an incorrect admission date, no 
payment can be made on this claim. Therefore, we decided that the Plan does not have to pay for the home 
health services provided May 19, 2022, to June 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on July 12, 2022. 
 
You asked the Plan to pay for the drug testing. You say that the records support the services billed. The Plan 
denied your request. The Plan says the laboratory order does not show 22 or more drug classes were ordered. 
 
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 G0483 is drug testing of 22 or more drug classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the physicians order does 
not clearly show the intent to order 22 or more drug classes. Further, there is no documentation showing which 
drugs are included in the panels ordered by the physician. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to 
pay for the drug testing provided on July 12, 2022.