Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine 
(Tdap) (90715) and administration (90471) provided on August 26, 2022. 
 
You asked the Plan to pay for the immunization. You say that your family doctor recommended you get this 
booster. You say that you were never advised it would only be covered if it was received at the pharmacy. You 
also say that if you had known that you would have gone to a pharmacy. The Plan denied your request. The 
Plan says the immunization is not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the immunization. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the immunization. 
Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular 
pertussis vaccine (Tdap) (90715) and administration (90471) provided on August 26, 2022.  
 
Benefits for the immunization 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH setting is necessary to 
perform the care and management required for the enrollee's medical complexities. The Plan denied your 
request. The Plan says the enrollee is not doing well with the attempts to be taken off the ventilator and services 
needed can be provided at current facility. 
 
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 appears to be more stable and improving, tolerating initial weaning trials 
and should only require short-term additional acute care services that can safely be provided at the current 
facility until more appropriate for a lower level of care. The enrollee does not require services at the LTACH 
that are not already available at the current facility. Completion of treatment at the current facility is 
recommended.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the 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: 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 say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 you appear to be more stable and improving and should only require short-term 
additional acute care services that can safely be administered at the current facility until you are more 
appropriate for a lower level of care. You do not require services at the LTACH that are not already available at 
the current 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says you do 
not meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. In this case, there are insufficient medical records to show that you 
use insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the 
blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the 
requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor.
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 do not agree with the denial and wants to appeal 
the decision. The Plan denied your request. The Plan says the IRF care is not medically necessary, and your 
needs can be met at a lower level of care, such as 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 you were admitted for cholecystitis and had a cholecystectomy. Your medical 
problems are stable, and there are no complex nursing or rehabilitation needs. You do 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. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lower 
extremity without contrast. 
 
You asked the Plan to pre-approve the MRI. You say that it is medically necessary for the enrollee to get an 
MRI. The Plan denied your request. The Plan says the enrollee has a fracture, and the medical necessity of the 
MRI has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
MRI of the lower extremity without contrast is not medically reasonable or necessary. Our physician reviewer 
found that the enrollee was being treated for spondylolisthesis of the lumbar region. The enrollee presented 
with left hip pain. The enrollee is weight-bearing in regular shoes. Their pain is 0 out of 10. The enrollee is not 
in therapy for their hip. The exam full range of motion with no hip. Strength and sensation are intact. 
 
However, the x-rays are noted to show a stable right total hip arthroplasty, and a non-displaced left inferior 
pubic rami fracture with interval healing. Additional, advanced, imaging studies are not typically supported 
unless the radiographs are non-diagnostic. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. 
 
 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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the lower extremity without contrast.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that your right foot is amputated. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for the requested device. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that your condition can be improved by a manual wheelchair. This means that Medicare rules 
for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service March 27, 2021, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that this should be paid for. The Plan denied 
your request. The Plan says code 99153 is not payable in the facility setting. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does not have to pay for the additional moderate sedation time provided on date of service March 27, 2021, billed 
with code 99153.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 26, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the provider is out-of-network and authorization was not obtained prior to 
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 provider at issue in this case is not a network provider with the Plan. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the office visit. Our reviewer says that the records do not indicate that the care 
provided was medically necessary. Our physician reviewer found the enrollee has a history of cardiomyopathy 
s/p AID, CVA x 2, nicotine abuse, and depression, and was seen to establish care. It would have been 
medically reasonable to delay the services until when enrollee returned to his/her service area. 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 office visit have not been met.  
 
The Plan has network providers available who can provide the items/services at issue in this appeal. We found 
no exception that would require the Plan to pay for the office visit. Therefore, we decided that the Plan does not 
have to pay for an office visit provided on October 26, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab test provided on September 12, 2022. 
 
You asked the Plan to waive the copayment for lab test. You say that you are disputing the share cost. The Plan 
denied your request. The Plan says this cost sharing was charged 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 $15 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $8.62, which is less than the $15 copayment for lab test. This item/service falls 
within the outpatient diagnostic tests and therapeutic services and supplies 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 lab test provided on September 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
April 11, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service April 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for date of service 
January 24, 2022. 
 
You asked the Plan to pay for procedure codes 99601 and 99602. You say that previous claims with the same 
services have been paid. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes 99601 and 99602 have a Status Indicator of I on the Physician Fee Schedule. 
This means that procedure codes 99601 and 99602 are not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 99601 and 99602 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for 
date of service January 24, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for upper gastrointestinal endoscopic procedures 
provided on May 23, 2022. 
 
You asked the Plan to pay for anesthesia for upper gastrointestinal endoscopic procedures. The Plan denied 
your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered 
services related or unrelated to the members terminal condition. The Medicare hospice benefit, through fee-
for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or 
revocation. During the election, fee-for-service Medicare also covers attending physician services and all care 
unrelated to the terminal illness until the first day of the month following the month in which hospice was 
revoked or discharged. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on May 9, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for anesthesia for upper 
gastrointestinal endoscopic procedures provided on May 23, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital care provided to the enrollee from January 22, 2022, 
to January 27, 2022. 
 
You asked the Plan to pay for the inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says that authorization was not obtained prior to services being 
rendered. 
 
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson 
standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be 
such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of 
immediate medical attention would result in serious jeopardy to their health.  
 
We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with 
an average knowledge of medicine would reasonably expect the absence of immediate medical care to 
seriously jeopardize their health in this case. Therefore, we decided that the Plan has to pay for inpatient 
hospital care provided to the enrollee from January 22, 2022, to January 27, 2022.  
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) provided on March 
21, 2022. 
 
You asked the Plan to pay for the DME. You say that the enrollee was discharged from hospice prior to the 
date of service in this case. The Plan denied your request. The Plan says the enrollees claim would be covered 
under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until 
the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on March 16, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the durable medical 
equipment (DME) provided on March 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stelara. 
 
You asked the Plan to pre-approve Stelara. The Plan denied your request. The Plan says drugs supplied by the 
pharmacy are not covered by Medicare Part B. 
 
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, 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 Stelara.  
 
Benefits for Stelara 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Aranesp. 
 
You asked the Plan to pre-approve Aranesp. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step-therapy rules for coverage of the requested drug 
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 Aranesp. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of drugs Retacrit or Procrit before they will approve the requested drug. The enrollee has 
not tried and failed the required drugs. The available documentation does not support that Retacrit or Procrit 
would likely be less effective and/or would likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Aranesp.