Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for part of your drug treatment service code 940. It 
should have a 20% coinsurance instead of a $35 copay ($59.82 allowed x 20% coinsurance = $11.96).   We 
decided that the Plan does not have to waive the coinsurance for the remaining drug charges  
 
You asked the Plan to waive the coinsurance for cancer treatments provided from July 14, 2021, to July 15, 
2021. You say that you had cancer and cannot afford these copayments. The Plan says that you were charged 
this cost sharing correctly. 
 We decided that the Plan has to waive the coinsurance for part of your drug treatment service code 940. 
It should have a 20% coinsurance instead of a $35 copay.  
 
The Plan follows Medicare rules. Medicare rules say that part of your drug treatment service code 940 should 
have a 20% coinsurance instead of a $35 copay ($59.82 allowed x 20% coinsurance = $11.96). This means you 
were overcharged by $23.04. Therefore, we decided that the Plan has to waive the coinsurance for part of your 
drug treatment service code 940. It should have a 20% coinsurance instead of a $35 copay.  
 
We also decided that the Plan does not have to waive the coinsurance for the remaining drug charges. 
 
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 a 20% 
coinsurance for the remaining drug charges. Therefore, we decided that the Plan does not have to waive the 
coinsurance for the remaining drug charges. Drugs/Drug Administration on July 14, 2021 - $130.38 
coinsurance Drugs/Drug Administration on July 15, 2021 - $660.38 coinsurance. 
 
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 pay for the inpatient hospital services rendered from May 18, 2021, 
to May 22, 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 submitted records do not support the billing of secondary diagnosis code J96.01. 
 
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 J96.01. 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 these services. Our reviewer says that the submitted records do not support the 
billing of secondary diagnosis code J96.01. Our physician reviewer found the enrollee was admitted to the 
hospital with abdominal pain. The documentation supported an admission for appendicitis.  Post-appendectomy 
the enrollee was extubated to four liters of oxygen which was decreased to two liters. She was the  weaned to 
room air on May 20, 2021. She was noted to have an oxygen saturation of 87 percent and a chest x-ray was 
obtained. She was presumed to have atelectasis and her oxygen returned to normal. There was no 
documentation of acute hypoxic respiratory failure. The review has determined that the records did not support 
the billing of J96.01.  
 
We looked at this physician'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 hospital services rendered from May 18, 2021, to May 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxycodone. 
 
You asked the Plan to pre-approve Oxycodone. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this drug is not 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 Oxycodone.  
 
Benefits for Oxycodone 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the F1CDx genetic testing services. 
 
You asked the Plan to pay for the F1CDx genetic testing services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this claim has not been 
billed as required by Medicare billing regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must include the unique test identifier 
on the claim for the molecular testing. Based on this information, we decided that Medicare rules for coverage 
of the F1CDx genetic testing services have not been met. Therefore, we decided that the Plan does not have to 
pay for the F1CDx genetic testing services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiology office visit provided on March 11, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the cardiology office visit. You say that the service was medically necessary. The 
Plan denied your request. The Plan says no prior authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the cardiology office visit. The Plan did not pre-approve the cardiology 
office visit. We found no exception that would require the Plan to pay for the cardiology office visit. The 
records provided for review do not show that the cardiology office visit was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the cardiology office visit provided on March 11, 2022, by an 
out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve depo-testosterone. 
 
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 the services are not covered when not incident to physician services. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve depo-testosterone.  
 
Benefits for these services 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: 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 drug is medically reasonable for the enrollee's 
condition. The Plan denied your request. The Plan says step therapy criteria 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 this 
drug is not medically necessary. Our physician reviewer found the Plan requires a trial of Forteo before they 
will approve the requested drug. In this case, the patient has not tried and failed the required drug(s). There is 
no documentation provided indicating that the Plans required drug(s) 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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary for the enrollee to be 
admitted to the hospital and they need rehabilitation services. The Plan denied your request. The Plan says the 
enrollee does not have complex rehabilitation, medical, and nursing needs. The enrollee does not need to be 
assessed medically and functionally or need supervision face-to-face by a rehabilitation doctor at least 3 days 
per week. The enrollee does not have medical conditions so complex that they need frequent monitoring by a 
doctor on an inpatient basis in an IRF. The enrollee's rehabilitation needs do not require an intensive team 
approach. The enrollee's needs can be met at an alternate level of care like a skilled nursing facility. 
 
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 enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for congestive heart failure. Medical problems are stable. There are no complex nursing 
or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
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 requested ventilator. You say that this is a medically necessary device to 
support the enrollee's breathing. The Plan denied your request. The Plan says criteria are not met. 
 
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 requested ventilator. Our reviewer 
says that the enrollee does not meet criteria for the requested ventilator. Our physician reviewer found the 
enrollee has chronic obstructive pulmonary disease (COPD) with a recent exacerbation. Arterial blood gases 
were consistent with acute-on-chronic hypercarbic respiratory failure. The enrollee improved with bilevel 
positive airway pressure (BiPAP) and may benefit from this in the home with average volume-assured pressure 
support (AVAPS). This has not been tried. 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 requested ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sterile gloves used during an emergency department (ED) 
visit provided on May 10, 2022, billed with code A4930. 
 
You asked the Plan to pay for the billed code A4930. You say that you feel that the rate reduction applied for 
the rendered services is unfair and does not adequately cover the costs associated with the enrollee's care. The Plan denied your request. The Plan says this claim has been paid correctly as code A4930 is not separately 
paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Code A4930 has a status indicator of "N" in the Outpatient Prospective Payment System (OPPS). This means 
that no separate payment is made for this code since it is packaged. Based on this information, we decided that 
Medicare rules for coverage of the billed code A4930 have not been met. Therefore, we decided that the Plan 
does not have to pay for the sterile gloves used during an emergency department (ED) visit provided on May 
10, 2022, billed with code A4930.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from March 31, 
2022, to April 29, 2022. 
 
You asked the Plan to pay for SNF care. You say that it is felt that Medicare payment should be made for the 
services. The Plan denied your request. The Plan says the services at issue do not meet criteria for Medicare 
coverage. 
 
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 pay for 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 the enrollee did not have documented skilled nursing needs. The enrollee did not 
have documented skilled therapy needs. Daily skilled services were not required to establish a maintenance 
program or to prevent deterioration of the enrollees condition. The enrollees care needs could, 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 pay for skilled nursing facility (SNF) care provided from March 31, 2022, to April 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services coded 81455 provided on 
February 21, 2022. 
 
You asked the Plan to pay for the genetic testing services coded 81455. You say that you would like this claim 
reprocessed and approved for payment based on the medical records submitted. The Plan denied your request. 
The Plan says this code is not covered per Medicare billing rules. 
 
The Plan must follow Medicare rules. Medicare rules say that prior to April 1, 2022, code 81455 was a tier 1 
non-covered code for which genetic testing is unlikely to impact therapeutic decision-making in the clinical 
management of the patient and will be denied automatically as not medically necessary. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing services coded 81455 have not 
been met. Therefore, we decided that the Plan does not have to pay for the genetic testing services coded 81455 
provided on February 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nebulizer and oscillatory positive expiratory pressure 
device purchased on April 4, 2022, from a provider not certified with the Medicare. 
 
You asked the Plan to pay for the nebulizer and oscillatory positive expiratory pressure device. You say that 
you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says 
payment cannot be made to a supplier not certified with the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the nebulizer and oscillatory positive 
expiratory pressure device purchased on April 4, 2022, from a provider not certified with the Medicare.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 7, 2022. 
 
You asked the Plan to pay for laboratory services. You say that service was medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of comprehensive pharmacogenetic 
testing have not been demonstrated in the peer-reviewed literature. The denial of the comprehensive 
pharmacogenetic panel was appropriate given the clinical scenario and the guidance presented above. 
 
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 CPT code 81241, 81226, 0033U, 81306, 81401, 81355, 81240, 81231, 81227, 81335, 81225, 
0032U, 81328, 81230, 81232, 81291 are not supported in the medical record. Specifically, the enrollee does not 
meet criteria for the requested testing. Based on this information, we decided that Medicare rules for coverage 
of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for 
laboratory services provided on March 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health (HH) skilled nursing (SN) visits (CPT 
code G0299). 
 
You asked the Plan to pre-approve the home health skilled nursing visits. You say that the services are 
necessary. The Plan denied your request. The Plan says the enrollee's records do not support the need for a 
skilled nurse to make more visits. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
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 health skilled nursing visits. 
Our physician reviewer found the enrollee does not have documented skilled nursing needs. As such, the 
requested, ongoing, HH SN services are not medically necessary or reasonable. 
 
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 health skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the home health (HH) skilled nursing (SN) visits (CPT code G0299).
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 the enrollee had a fall and fractured her back. 
Additional rehabilitation is needed for the enrollee to become stronger and be able to return home safely. The 
Plan denied your request. The Plan says the requested service is not reasonable and necessary and the enrollee 
does not meet Medicare criteria. 
 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 the enrollee was at a contact guard to minimal assist level with functional mobility 
including gait to short distances and requires varying assist with activities of daily living skills. The enrollee 
does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a 
skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized 
skill, knowledge, and judgment of a skilled professional therapist. Our reviewer also found the enrollee does 
not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 
setting. 
 
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.