Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on August 2, 2022. 
 
You asked the Plan to pay for the home health services. You say that Notices of Admission (NOAs) are not 
required for participating providers. The Plan denied your request. The Plan says you billed these services with 
an incorrect Type of Bill on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that that home health services must be billed with the 
correct Type of Bill. Home health services under a Plan of Treatment are billed with Type of Bill 032x. The 
fourth digit should be one of the following: 7 indicates a replacement of a prior claim, 8 indicates a void/cancel 
of a prior claim, and 9 indicates a final claim for a home health period. 
 
Based on this rule, you should have billed the services in question with Type of Bill 0329.  Instead, you billed 
with 0323, which is not correct.  Please note that this denial did not have to do with the presence or absence of 
a NOA.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to 
pay for home health services provided on August 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearings aids (V5261) purchased on 
October 5, 2022. 
 
You asked the Plan to issue reimbursement 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 payable as 
they were not ordered through the Plan's select hearing aid provider. 
 
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 ordered through the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are covered 
when ordered through the Plans select hearing aid provider.  To access your hearing aid benefit, you must contact the Plans select hearing aid provider. Hearing aids 
ordered through other providers, are not covered. The hearing aids in this case were not ordered through the 
Plans select hearing aid provider. Therefore, we decided that the Plan does not have to issue reimbursement 
for the hearings aids (V5261) purchased on October 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 26, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that the test was needed to help determine the course of 
treatment. The Plan denied your request. The Plan says authorization is required for certain services. 
 
 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 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 lab services provided on October 26, 2022, 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission. You say you need rehabilitation in order to walk again. The Plan denied your request. The 
Plan says you do not meet the medically necessary criteria for an IRF admission. 
 
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 your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
surgical management of bilateral lower extremity fractures and non-surgical management of rib and pelvic 
fractures after being struck by a motor vehicle. Your medical problems are stable and there are no complex 
nursing or rehabilitation needs. While the medical record supports a need for physical or occupational therapy, 
there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different 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 IRF admission and services.
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 you are requesting an expedited 
reconsideration for the denial of an LTACH admission. You say the enrollee will require an LTACH level of 
care and is currently stable for discharge. The Plan denied your request. The Plan says the LTACH services 
requested do not meet the requirements for approval. 
 
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 that the enrollee has ongoing acute medical issues and still requires acute care 
services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and 
these have not been denied by the Plan. The medical record does not indicate that the enrollee requires services 
that they are not currently receiving but that would be available at the LTACH 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro powered arm brace. 
 
You asked the Plan to pre-approve a MyoPro powered arm brace. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a MyoPro powered arm brace. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a history of left upper extremity partial paralysis from a 
brachial plexus injury due to a motor vehicle accident. The MyoPro Orthosis is not known to be effective, 
based on scientific evidence, professional standards and expert opinion, in improving health outcomes. The 
MyoPro is not the standard of care for this enrollee's brachial plexus condition or in widespread use for this enrollee's condition based on scientific evidence. There is insufficient evidence in the literature that the 
MyoPro Orthosis will improve the long-term outcomes for this enrollee. There is insufficient evidence in the 
literature that this device will increase participation in bimanual activities. Therefore, the enrollee does not 
meet criteria for the requested device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a MyoPro powered arm brace have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro powered arm brace.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the out-of-network cost share for the injections (20610 x 2) provided on 
April 21, 2022. 
 
You asked the Plan to waive the out-of-network cost share for the injections. You say that you were only given 
a copayment for one of the shots, not both. You say that you were late in appealing this because you were 
advised by a plan representative that they would look into the mistake and get back to you. You say that no one 
ever called you back. The Plan denied your request. The Plan says that the out-of-network cost share was 
applied correctly to these services. 
 
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 Plan has not substantiated their denial. The provider in this case 
is noted to be in-network according to the Evidence of Benefits. Therefore, we decided that the Plan has to 
waive the out-of-network cost share for the injections (20610 x 2) provided on April 21, 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: 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 you are requesting reconsideration for 
the denial of an LTACH admission. You say going home endangers the enrollee's life and places them at risk 
of death. The Plan denied your request. The Plan says the LTACH services requested do not meet the 
requirements for approval. 
 
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 that the enrollee has ongoing acute medical issues and still requires acute care 
services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and 
these have not been denied by the Plan. The medical record does not indicate that the enrollee requires services 
that they are not currently receiving but that would be available at the LTACH 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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81479) provided on June 23, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this test was reported correctly. The Plan 
denied your request. The Plan says the code used to report this test is not supported in the medical record. The 
services at issue would be better reported with code 85025. 
 
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 81479 is unlisted molecular pathology procedure. 
 
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 laboratory services. Our reviewer says that code 81479 is not 
supported by the documentation submitted. Our reviewer found the laboratory results in the record indicate that 
a complete blood count (CBC) was performed. There are no lab results supporting the performance of an 
unlisted molecular pathology code. We looked at this coder's review, the file, and Medicare rules. 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 (81479) provided on June 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous implantation of the SPRINT PNS device 
(64555). 
 
You asked the Plan to pre-approve the SPRINT PNS device. You say that the service is medically necessary. 
The Plan denied your request. The Plan says this service is considered experimental. 
 
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 SPRINT PNS device. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found this service is considered experimental. 
 
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 SPRINT PNS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a percutaneous implantation of the SPRINT PNS device (64555).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for May 24, 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 procedure code 99223 is not supported. 
 
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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit.  
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 these services. Our reviewer says that procedure code 99223 
is not supported. Our reviewer found CPT code 99223 can be used for an initial hospital care evaluation and 
management of a patient that requires 3 key components. The 3 key components are a comprehensive history, 
comprehensive examination and medical decision making of high complexity. Usually, the medical problem 
that requires admission is of high severity and 70 minutes are spent at the bedside and on the patients hospital 
floor or unit. In this case, the documentation doesnt support the CPT code 99223.  The documentation doesn't 
indicate the medical decision making was of high complexity. 
 
We looked at this coder'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 pay for procedure code 99223 billed for May 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) (E0675) and 
appliance (E0673) provided on September 22, 2022. 
 
You asked the Plan to pay for the PCD and appliance. The Plan denied your request. The Plan says this is not 
covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device (PCD) (E0675) and appliance (E0673) provided on 
September 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lucentis. 
 You asked the Plan to pre-approve Lucentis. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements 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 Lucentis. Our reviewer says that the 
requirements for coverage of Lucentis have not been met. Our physician reviewer found the Plan requires a 
trial of Avastin (bevacizumab) before they will approve Lucentis. The record does not indicate the enrollee has 
tried and failed Avastin. The documentation does not support that Avastin would likely be less effective or 
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 Lucentis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Lucentis.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya (J3245). 
 You asked the Plan to pre-approve Ilumya. You say that the enrollee has failed treatment with MTX, 
clobetasol, tacrolimus, Otezla, Tremfya, and Stelara. You say that the enrollee has a needle phobia. You also 
say that the enrollee is okay with Stelara self-injections. The Plan denied your request. The Plan says the 
enrollee has not tried and failed the preferred drugs. 
 
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 Ilumya. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
the enrollee trialed and failed treatment with Renflexis, Inflectra, Skyrizi, Taltz, Humira, and Enbrel. The 
reviewer found that the documentation does not support that Renflexis, Inflectra, Skyrizi, Taltz, Humira, and 
Enbrel would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 
Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya (J3245).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from March 27, 2022, to 
March 28, 2022. 
 
You asked the Plan to pay for the inpatient care. You say that the services were medically necessary. The Plan 
denied your request. The Plan says unauthorized, out-of-network care is not covered. Observation care has 
been approved. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
 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 inpatient care. Our reviewer says that the 
records do not indicate that the care provided was medically necessary. Our physician reviewer found the 
inpatient admission was not medically necessary, but an observational level of care was medically 
appropriate.  The enrollee could have been safely transferred to an in-network facility for ongoing 
observational 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 the inpatient care have not been met. Therefore, we decided that the Plan does 
not have to pay for inpatient hospital care provided from March 27, 2022, to March 28, 2022.