Persius/hicric huggingface dataset:
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 no need for physician supervision 3 times per week (at a minimum) for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the 
current level of function, the enrollee does not require an intensive, complex, multidisciplinary approach to 
daily therapy. Documentation does not support the need for a therapy program consisting of at least 3 hours of 
therapy per day at least 5 days per week with an interdisciplinary approach to rehabilitation care. While the 
enrollee may benefit from physical therapy and occupational therapy, the rehabilitation needs can be safely met 
in an alternate and lower intensity 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 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: Testing
Decision: Favorable

 
We decided that the Plan has to waive the copayment for a diagnostic colonoscopy provided on October 29, 
2021. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you were told there 
would be no copayment for the procedure. You also say you have a history of polyps. The Plan denied your 
request. The Plan says that you have been charged the correct cost sharing amount. 
 
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. The Plan did not provide medical records to show the colonoscopy was 
diagnostic or if polyps were removed. Without medical records we are unable to determine if cost sharing 
applies. Therefore, we decided that the Plan has to waive the copayment for a diagnostic colonoscopy provided 
on October 29, 2021.  
 
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. 
 
Your complaint about being told there was no copayment is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that this should be covered under the enrollee's prescription 
benefit. You say that you do not do buy and bill. You also say that you billed the enrollee's insurance thinking 
that it was a Part D plan. The Plan denied your request. The Plan says the requested drug is not covered by 
Medicare Part B when it is supplied by a pharmacy. 
 
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 Prolia (J0897).  
 
Benefits for Prolia may be available under the enrollees Medicare Part D plan. Contact the enrollees Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office or other outpatient visit for the evaluation and 
management of an established patient, which requires a medically appropriate history and/or examination and 
high level of medical decision making (99215) provided on July 30, 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 these services do not meet criteria for OON coverage. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making (99215) provided on July 30, 2021, by an out-of-
network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that therapy will increase your strength and coordination, 
and likely prevent future hospitalizations and dependence of medications for pain. The Plan denied your 
request. The Plan says the requested 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 the provided documentation indicates that your medical problems are stable. There 
are no complex nursing or rehabilitation needs. The reviewer found that while you have a need for physical 
and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. The 
reviewer also found that 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 IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services (90834) provided on June 21, 2021. 
 
You asked the Plan to pay for psychotherapy services. You say that you would like reconsideration because 
these services were provided to the enrollee in good faith. The Plan denied your request. The Plan says there 
was no documentation of contact with the enrollee's physician in the record. The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy services have not been met. Specifically, the record does not include documentation 
of a consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare 
rules. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90834) provided on 
June 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed. 
 
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 medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that hospital beds are covered when specific criteria 
are met. 
 
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 these services. Our reviewer says that the criteria for coverage are not met. Our physician reviewer found the enrollee has a body mass index (BMI) 
of 58.97 and uses chronic oxygen supplementation via tracheostomy. The records indicate he is independent 
with mobility and ambulation and no longer requires physical therapy. He is not bed bound. The records did 
not clearly indicate that he requires position adjustments or other needs that would not be effectively met with a 
regular bed. The requested hospital bed is therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. 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 a heavy duty extra wide hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuromuscular reeducation of movement, balance, 
coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities, 
Transcutaneous Electrical Nerve Stimulation (TENS), vasopneumatic device, subcutaneous injection of FDA 
Nutri-Pharmaceutical blend provided on September 29, 2020. 
 
You asked the Plan to pay for neuromuscular reeducation of movement, balance, coordination, kinesthetic 
sense, posture, and/or proprioception for sitting and/or standing activities, Transcutaneous Electrical Nerve 
Stimulation (TENS), vasopneumatic device, subcutaneous injection of FDA Nutri-Pharmaceutical blend. The 
Plan denied your request. The Plan says that the denial of Sanexas neoGen-Series Therapy (electrical cell 
stimulation), vasopneumatic device therapy, and the associated codes for the subcutaneous injection of FDA 
Nutri-Pharmaceutical blend was appropriate given the clinical scenario and the guidance. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical 
therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private 
practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that 
NP/PA may perform physical therapy services under State law. The rules say that beginning in July 2015, 
claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) 
code. The rules say the use of vasopneumatic devices may be considered reasonable and necessary for the 
application of pressure to an extremity for the purpose of reducing edema or lymphedema.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or 
proprioception for sitting and/or standing activities, Transcutaneous Electrical Nerve Stimulation (TENS), 
vasopneumatic device, subcutaneous injection of FDA Nutri-Pharmaceutical blend have not been met. 
Therefore, we decided that the Plan does not have to pay for neuromuscular reeducation of movement, balance, 
coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities, 
Transcutaneous Electrical Nerve Stimulation (TENS), vasopneumatic device, subcutaneous injection of FDA 
Nutri-Pharmaceutical blend provided on September 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dermatology services provided on July 9, 2021, to 
September 14, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that documentation supports the medical necessity of 
the visit. The Plan denied your request. The Plan says there are no records of a prior authorization being 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the dermatology services provided on July 9, 2021, to September 14, 2021, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 12, 2021. 
 
You asked the Plan to pay for the lab services. You say that there is no agreement that the codes are included in 
the dialysis rate. The Plan denied your request. The Plan says the lab tests are the responsibility of the dialysis 
center. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on October 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a teletyperwriter. 
 
You asked the Plan to pre-approve the teletyperwriter. You say that the teletyperwriter is medically necessary. 
The Plan denied your request. The Plan says this device is not eligible for coverage. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 
 
 
 
 
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a teletyperwriter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies provided on September 28, 2021. 
 
You asked the Plan to pay for the services provided. You say that you supplied the services at your own cost. 
The Plan denied your request. The Plan says the claim was billed with an invalid code. 
 
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 looked at the file and the rules. We find that CPT code S1015 and S8301 are not valid for Medicare 
purposes. Medicare uses another code for the reporting of, and payment for, these services. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the supplies provided on September 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane. 
 
You asked the Plan to pre-approve Durolane. You say that you are in pain that has been ongoing for 5 weeks. 
You say that you prefer 1 injection to 3 and it is difficult to travel with your condition at your age. The Plan 
denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that there is 
no record showing that the enrollee has tried one of the preferred drugs, or that there are medical reasons 
preventing him from using one of them. 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 Durolane. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the enrollee has not trialed 
viscosupplemental treatments such as Orthovisc, Synvisc, or Synvisc-One.  Step therapy, as outlined by the 
plan, requires that one of these be trialed first. The documentation does not outline contraindications or reasons 
these medications were not considered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chest x-ray (procedure code 71045) provided to the 
enrollee on April 26, 2021. 
 
You asked the Plan to pay for the x-ray. You say that this should be paid for. The Plan denied your request. The 
Plan says separate reimbursement is not recommended. 
 
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 71045 is "Radiologic examination, chest; single view." 
 
We asked our coder 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 x-ray. Our reviewer says that the services at issue in this 
case were not supported by the medical records. Our reviewer found in this case, modifier 26 is inappropriate. 
The provider documents this procedure was performed for post left thoracentesis. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a chest x-ray (procedure code 71045) provided to 
the enrollee on April 26, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve visual field assessment tech support for 3 months 
(0379T). 
 
You asked the Plan to pre-approve the visual field assessment. You say that the requested service is covered by 
Medicare. You say that there are no other providers that perform this testing. You also say that an exception 
should be made. The Plan denied your request. The Plan says the requested service is not covered. 
 
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 visual field assessment. Our 
reviewer says that the requested visual field assessment is not considered medically reasonable and necessary 
in this case. Our physician reviewer found the record indicates that the enrollee has nonexudative age related 
macular degeneration, bilateral, intermediate dry stage. The record submitted does not contain recent medical 
records supportive of the requested service. The provided records are insufficient to determine the medical 
necessity and reasonableness, as defined by Medicare rules, of the requested service for the enrollee's specific 
clinical condition. Therefore, the reviewer found that the requested visual field assessment is not medically 
necessary. 
 
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 visual field assessment have not been met. Therefore, we decided that the 
Plan does not have to pre-approve visual field assessment tech support for 3 months (0379T).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on May 14, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied code G0483 remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for drug testing services provided to the enrollee on May 14, 2021.