Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675, E0673) provided 
April 7, 2021. 
 
You asked the Plan to pay for the pneumatic compression device. You say that the device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
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 pneumatic compression device. Our 
reviewer says that the requested device is not medically necessary. Our physician reviewer found the treating 
physician failed to provide documented evidence of ongoing significant benefit, then the medical record 
documentation must provide other clear evidence of medical necessity for treatments. The review has 
determined that the requested device is not medically necessary considering this device is not covered for 
peripheral artery disease. 
 
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 pneumatic compression device have not been met. Therefore, we decided 
that the Plan does not have to pay for a pneumatic compression device (E0675, E0673) provided April 7, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you need therapy and if you return home you 
will continue to decline. You say that you are at risk of loss of function and mobility. The Plan denied your 
request. The Plan says they did not receive records to support that the enrollee needs daily skilled services in 
the SNF. The Plan says that the enrollee can safely receive the services needed in a hospital.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications 
and had stable vital signs. The enrollee received physical therapy and was at contact guard to minimal assist 
level with functional mobility, including gait to short distances with a hemi-walker. There are no identifiable 
skilled nursing service needs. There are identifiable skilled therapy service needs, but they are not required on a 
daily basis. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient 
basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided August 11, 2020 to August 
22, 2020. 
 
You asked the Plan to pay for the inpatient hospital care. You say that the services were medically necessary 
and correctly billed. The Plan denied your request. The Plan says DRG 273 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 273. 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 hospital care. Our reviewer says that the records provided do not 
support the DRG billed. Our physician reviewer found there was no documentation of acute respiratory failure. 
The review has determined that the records support did not DRG 273. The appropriate DRG is 274.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital care provided August 11, 2020 to August 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Buspirone 5 mg tablet.
You asked the Plan to pre-approve Buspirone tablet. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for self-administered drugs have not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Buspirone 5 mg tablet.
Benefits for Buspirone tablet 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 waive the copayment for inpatient mental health care you received 
from May 25, 2021, to June 4, 2021. 
 
You asked the Plan to waive the copayment for the inpatient mental health care. You say that you are on 
disability and cannot afford expensive hospital bills. The Plan denied your request. The Plan says you were 
charged this copayment 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 $230 
copayment per day for days 0-8, and a $0 copayment per day for days 9-90 for inpatient mental health care at 
an inpatient psychiatric facility.  
 
Records show that you received inpatient mental health care at an inpatient psychiatric facility for 10 days.  
You were charged a $230 copayment per day for the first 8 days, for a total of $1840.  This copayment applies 
regardless of the reason for the length of your stay. 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 
inpatient mental health care you received from May 25, 2021, to June 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on February 4, 2021.
You asked the Plan to pay for the services provided. You say that the original payment was recouped in error. The Plan denied your request. The Plan says the service does not meet the standards of claim coding.
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 99204 is office or other outpatient visit for the evaluation and management of a new patient. We find that CPT code 99204 is not supported. The case file shows that the enrollee received professional services from this physician within the previous 3 years. This means that the enrollee was not considered a new patient on the date of service at issue. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the office visit provided on February 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Reblozyl for the enrollee.
You asked the Plan to pre-approve Reblozyl. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the clinical value and effectiveness of Reblozyl in the setting of chronic myeloproliferative disease without ring sideroblasts has not been demonstrated in the peer-reviewed literature.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Reblozyl. Our reviewer says that Reblozyl is not medically reasonable and necessary for the enrollee. Reblozyl is not FDA-approved for the enrollee's diagnosis. The use of Reblozyl is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 Reblozyl have not been met. Therefore, we decided that the Plan does not have to pre-approve Reblozyl for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test provided on June 10, 2021, by an OON 
provider. 
 
You asked the Plan to pay for the laboratory service. You say that the service was medically necessary. The 
Plan denied your request. The Plan says prior authorization was not obtained before the services were rendered 
to the enrollee. The Plan also says that the service was not urgent or emergent in nature. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must 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 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 drug test provided on June 10, 2021, by an 
OON provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from May 1, 2021, to May 3, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that you would like this denial to be reconsidered for coverage. The Plan denied your request. The Plan says that the information provided does not show that the enrollee had a low blood oxygen level, severe trouble breathing requiring them to work hard to breathe or need for a machine to help them with breathing.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from May 1, 2021, to May 3, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to hold you harmless for the outpatient services provided on June 25, 2020, 
through May 17, 2020. 
 
You asked the Plan to hold you harmless for the outpatient services. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says that they are 
unable to identify the service rendered and what was purchased based on the incomplete information submitted 
by the member. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the outpatient services by a contract provider. The file does not show that the Plan 
provided notice that the outpatient services would not be covered. Under Medicare rules, this means the 
outpatient services is considered approved by the Plan. Therefore, we decided that the Plan has to hold you 
harmless for the outpatient services provided on June 25, 2020, through May 17, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zoledronic Acid for the enrollee.
You asked the Plan to pre-approve Zoledronic Acid. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not supported for the enrollee.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Zoledronic Acid. Our reviewer says that Zoledronic Acid is not medically reasonable and necessary for the enrollee. Zoledronic Acid is not FDA-approved for the enrollee's diagnosis. Zoledronic Acid is FDA approved for hypercalcemia of malignancy (albumin-corrected serum calcium =12 mg/dL). The use supported of Zoledronic Acid is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Zoledronic Acid. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zoledronic Acid have not been met. Therefore, we decided that the Plan does not have to pre-approve Zoledronic Acid for the enrollee.
Appeal type: Drugs
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 the 
required criteria has not been met. 
 
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. The documentation does not indicate 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CxBladder testing (0012M) provided on April 19, 2021.
You asked the Plan to pay for CxBladder testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that non-coverage has been reaffirmed for codes 0012M and 0013M for CxBladder. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CxBladder testing have not been met. Therefore, we decided that the Plan does not have to pay for CxBladder testing (0012M) provided on April 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nuedexta. 
 
You asked the Plan to pre-approve Nuedexta. You say that this is medically necessary. The Plan denied your 
request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan. 
 
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 Nuedexta.  
 
Benefits for Nuedexta 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cardiac catheterization procedure you 
had at an ambulatory surgery center on June 17, 2021. 
 
You asked the Plan to waive the copayment for the cardiac catheterization procedure. You say that you had two 
clogged arteries, and you don't understand why the two procedures couldn't have been done at the same time.  
You stated that you shouldn't have to pay two separate copayments. The Plan denied your request. The Plan 
says you were charged this copayment 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 $275 
copayment for outpatient surgery and services at an ambulatory surgical center.  
 
You have been asked to pay a $275 copayment for the cardiac catheterization procedure. This is a per-service 
copayment and it applies regardless of the reason why you had two separate procedures. 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 the cardiac catheterization procedure you had at an ambulatory 
surgery center on June 17, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that you are unable to walk and cannot get into a 
standing position. You say that you have not progressed enough to transition to home care. You say that you 
are on dialysis, still are catheterized, and are not getting sufficient therapy at the current facility to help 
improve the mobility in your legs. The Plan denied your request. The Plan says the enrollee has not made any 
progress over the past 2 weeks and would not benefit from any additional therapy. 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have 
documented skilled nursing needs.  The enrollee does not have documented skilled therapy needs.  The enrollee 
appears to have reached a plateau in function.  Ongoing, daily skilled services are not required to establish a 
maintenance program or to prevent deterioration of the enrollee's condition.  The enrollee's care needs are 
custodial and, as a practical matter, can be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha Sureclick for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this was denied as a benefit exclusion.
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 Repatha Sureclick for the enrollee.
Benefits for this drug 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 Enbrel Sureclick.
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 self-administered drugs are not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Enbrel Sureclick.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.