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

 
We decided that the Plan does not have to pay for the self-administered drugs (A9270) provided from March 3, 
2022, through March 8, 2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not a covered benefit under your 
contractual policy or by Medicare. 
 
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 provided are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
(A9270) provided from March 3, 2022, through March 8, 2022.  Benefits for these items 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 use of a home ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that you are appealing this denial. The Plan denied your 
request. The Plan says the denial of this device is correct, because a ventilator is not covered by Medicare when 
used in this way and your needs could be met by bi-level positive airway pressure (BiPAP) device with average 
volume-assured pressure support (AVAPS) mode instead. 
 
The Plan must follow Medicare rules. Medicare rules say that a ventilator is not covered when used to provide 
positive airway pressure (PAP) therapy, regardless of the underlying medical condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a home ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would lack the ability to 
regain maximum function at a lower level of care. The Plan denied your request. The Plan says rules for 
LTACH care have not been met. 
 
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 enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a polysomnography (95810). 
 
You asked the Plan to pre-approve a polysomnography. The Plan denied your request. The Plan says this is not 
a covered benefit as there are no doctor notes to help establish medical necessity for the sleep study. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a polysomnography (95810). have 
been met. Medical records were not provided for this case. The record shows that the Plan made multiple 
attempts to obtain records, but they were not provided. Without this information, we cannot determine if the 
requested service is medically necessary. Therefore, we decided that the Plan does not have to pre-approve a 
polysomnography (95810).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Modafinil 100 mg tablets 
 
You asked the Plan to pre-approve Modafinil tablets. You say that the records provided should support the 
necessity of the requested service. The Plan denied your request. The Plan says the requested medication does 
not fall under Part B coverage. However, the enrollee may have a separate commercial pharmacy benefit or 
Medicare Part D benefit managed by another carrier. 
 
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 Modafinil 100 mg tablets  
 Benefits for Modafinil tablets 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: 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 meets Medicare criteria for IRF care and 
will benefit from acute inpatient rehabilitation that cannot be accomplished at a lower level of care. The Plan 
denied your request. The Plan says authorization denied because the IRF care is not medically necessary, and 
the enrollee's needs can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab 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, at an intensive rehabilitation therapy program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 you need rehabilitation therapy. The Plan denied 
your request. The Plan says a lower level of care might be appropriate. 
 
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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, at an intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. You continue to have a need for skilled therapy with ongoing 
safety concerns and a potential for functional improvement however, the documentation doesnt support that 
you would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that 
you would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the 
supervision of a physician with at least 3 visits weekly to regain or maintain your functional status. You can 
receive further services 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 surgical pathology rendered on February 17, 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 the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. 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 pay for the surgical pathology 
rendered on February 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71046 billed for date of service September 
23, 2021. 
 You asked the Plan to pay for procedure code 71046. You say that the enrollee was brought to your facility. 
The Plan denied your request. The Plan says this code is included in the skilled nursing facility payment and is 
not separately billable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the SNF for its Part A inpatients and are not separately payable. 
 
The records indicate that this service was provided to the enrollee while a SNF inpatient. Per the Physician Fee 
Schedule, CPT code 71046 has a Professional/Technical indicator of 1. This means that CPT code 71046 has 
both a professional and technical component. In this case, CPT code 71046 has not been billed with an 
appropriate modifier to indicate the professional component. Based on this information, we decided that 
Medicare rules for coverage of procedure code 71046 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 71046 billed for date of service September 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis provided on April 28, 
2022. 
 
You asked the Plan to pay for the shoulder elbow wrist hand orthosis. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the documentation does not support the need for the item 
rendered. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.   
The record does not contain a valid physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. The ordering Provider's office has confirmed they did not write 
the order for this item rendered. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the shoulder 
elbow wrist hand orthosis provided on April 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gauze provided on January 21, 2022 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for gauze. You say that wound care supplies are a separately billable expense that 
does not require authorization or referral. The Plan denied your request. The Plan says the denial of payment 
for this supply is correct, because this provider is out-of-network with the Plan and authorization was not 
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 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 gauze provided on January 21, 2022 by an out-of-
network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services billed with codes 99223, 99233, and 99497 
provided from January 6, 2022, to January 10, 2022. 
 
You asked the Plan to pay for codes 99223, 99233, and 99497. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
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 codes 99223, 99233, and 99497 are not supported in the medical record. Specifically, the 
claim was submitted with an invalid billing provider National Provider Identifier (NPI). This means this claim 
is not payable as billed. Based on this information, we decided that Medicare rules for coverage of codes 
99223, 99233, and 99497 have not been met. Therefore, we decided that the Plan does not have to pay for the 
services billed with codes 99223, 99233, and 99497 provided from January 6, 2022, to January 10, 2022.
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 this is medically necessary. The Plan denied your 
request. The Plan says the inpatient rehabilitation admission is needed. 
 
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 this enrollee with right hip fracture as described above does not meet CMS 
coverage criteria for IRF admission. She is medically stable with no medical complexity for physician supervision 3 times a week in an IRF. There are no acute rehab nursing needs identified or documented. At the 
current functional level, the enrollee does not need intensive therapies consisting of at least 3 hours of therapy 
per day at least 5 days per week with multidisciplinary approach. She needs physical theraoy and occupational 
therapy in an alternate setting. The enrollee's rehab needs can be safely provided in a lower intensity and 
alternate setting such as in an 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided from April 29, 
2022, to May 4, 2022. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you should not be responsible 
for this copayment. The Plan denied your request. The Plan says the copayment was applied correctly. 
 
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 $300 
copayment per day, for days 1 to 5 for Medicare-covered inpatient hospital stays.  
 
You have been asked to pay a $1500 copayment for an inpatient stay ($300 x 5 = $1500). An inpatient stay 
falls within the Medicare-Covered Inpatient Hospital stays 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 copayment for an inpatient stay provided from April 29, 2022, to May 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tissue exam by a pathologist (88305) billed for date of 
service June 25, 2021. 
 
You asked the Plan to pay for a pathologist tissue exam. You say that you have provided medical records to 
support the services billed. The Plan denied your request. The Plan says payment for the services at issue is 
included in the payment to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may be made under the physician fee 
schedule for the professional component of physician laboratory or physician pathology services furnished to 
hospital inpatients or outpatients. Payment is not made under the physician fee schedule for TC services 
furnished in institutional settings where the TC service is bundled into the facility payment, e.g., hospital inpatient and outpatient settings. 
 
We looked at the file and Medicare rules. In this case, the services at issue have not been billed with modifier 
-26 to identify the professional component. Based on this information, we decided that Medicare rules for 
coverage of a pathologist tissue exam have not been met. Therefore, we decided that the Plan does not have to 
pay for a tissue exam by a pathologist (88305) billed for date of service June 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pump assembly/operation services provided on May 4, 2022. 
 
You asked the Plan to pay for pump operation services. You say that these services should be processed 
separately from the hospital charges. The Plan denied your request. The Plan says the denial of payment for 
these services is correct, because the enrollee was a hospital inpatient on May 4, 2022 so these services are 
included in the facility payment and are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that all items and nonphysician services furnished to 
hospital inpatients must be furnished directly by the hospital or billed through the hospital under arrangements.  
 
We looked at the file and Medicare rules. The enrollee was a hospital inpatient on May 4, 2022; therefore, 
these services must be furnished directly by the hospital or billed through the hospital under arrangements and 
no separate payment is made. Based on this information, we decided that Medicare rules for coverage of pump 
operation services have not been met. Therefore, we decided that the Plan does not have to pay for pump 
assembly/operation services provided on May 4, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay an additional amount for the dialysis services (A4657, J1756, G0499, 
85041, 85048) provided from July 2, 2020, to July 30, 2020. 
 
You asked the Plan to pay an additional amount for the dialysis services. You say that the plan failed to pay the 
required amount for the service in this case. The Plan denied your request. The Plan says that the claim 
processed correctly. 
 
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. Specifically, the file does not clearly indicate why the services were denied. 
Therefore, we decided that the Plan has to pay an additional amount for the dialysis services (A4657, J1756, 
G0499, 85041, 85048) provided from July 2, 2020, to July 30, 2020.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing service, miscellaneous (V5299) provided March 
7, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aid parts. You say that your equipment was broken and needed to be 
fixed. The Plan denied your request. The Plan says this service is not covered because it was provided OON. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when provided through the Plans hearing vendor. 
 
We looked at the file and the Plan's rules. In this case the hearing aid service were provided OON without prior 
authorization. Based on this information, we decided that the Plan's rules for coverage of the hearing aid parts 
have not been met. Therefore, we decided that the Plan does not have to pay for the hearing service, 
miscellaneous (V5299) provided March 7, 2022, by an out-of-network (OON) provider.