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

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF is not 
medically necessary. 
 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 admission. Our reviewer says 
that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have any 
parental medication; complex wound care or nutrition given via a feeding tube. You are medically stable 
without any acute exacerbations of chronic medical problems. Your physical function was at or near your 
baseline and you could have received further services at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor supplies provided on 
December 12, 2021. 
 
You asked the Plan to pay for the services provided. You say that medical records were provided. The Plan 
denied your request. The Plan says the claim denied correctly. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
 
 
 The record does not contain a valid proof of delivery, for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the continuous glucose monitor supplies provided on December 
12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on February 15, 2022. 
 
You asked the Plan to pay for the services provided. You say that the enrollee meets criteria for genetic testing. 
The Plan denied your request. The Plan says the services are non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The file shows that the gene panel was provided due to a history anemia 
and unspecified thrombocytopenia. The records provided do not show that the enrollee has had 
thrombocytopenia for greater than 4 months. There are insufficient records to show that other possible causes 
have been ruled out. 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 lab testing 
services provided on February 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power operated vehicle, group 1 standard, patient 
weight capacity up to and including 300 pounds (CPT code K0800). 
 
You asked the Plan to pre-approve the DME. You say that you cannot bend over or pick anything up from the 
floor, you also cannot walk with the assistance of a cane, and you cannot even hold on to the walls. The Plan 
denied your request. The Plan says they were not provided with a physician's order and the necessary medical 
information needed to support your request for a small power wheelchair. The Plan states they received an 
order for a regular light wheelchair. 
 
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.  
 
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 DME. Our physician reviewer 
found clinical documentation does not meet LCD criteria. There is no information about mobility status with 
cane, walker or manual wheelchair. Additionally, it is noted that you would not be able to use a power mobility 
device in your home due to size and requests a light-weight manual wheelchair. 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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve power operated 
vehicle, group 1 standard, patient weight capacity up to and including 300 pounds (CPT code K0800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor supplies provided from 
November 29, 2021, to December 29, 2021. 
 
You asked the Plan to pay for the services provided. You say that you monitor the usage to ensure the enrollee 
has enough supplies. The Plan denied your request. The Plan says the documentation did not include a valid 
physician order. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  We looked at the file and the rules. The record does not contain a valid physician order or relevant medical 
records which support medical necessity for the supplies provided in this case. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for the continuous glucose monitor supplies provided from November 29, 2021, to 
December 29, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy (PT) and occupational therapy (OT) 
services provided on December 27, 2021. 
 
You asked the Plan to pay for the PT and OT services. You say that the services should be covered. The Plan 
denied your request. The Plan says the claim processed correctly. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the physical therapy (PT) and occupational therapy (OT) 
services provided on December 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous glucose monitor (CGM) supply allowance 
provided on February 6, 2022. You asked the Plan to pay for CGM supplies. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for these supplies is correct, because the 
documentation submitted does not include proof of delivery for the billed supplies. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of continuous glucose monitor (CGM) 
supply allowance provided on February 6, 2022. have been met. Specifically, the documentation submitted 
does not include proof of delivery for the specific supplies billed on this claim. Therefore, we decided that the 
Plan does not have to pay for continuous glucose monitor (CGM) supply allowance provided on February 6, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses provided on February 7, 2022. 
 
You asked the Plan to pay for the services provided. You say that fraudulent billing has occurred. The Plan 
denied your request. The Plan says the claim processed correctly. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
 
We looked at the file and the Plan's rules. The file shows that the provider billed the Plan for eyeglasses. The 
plan paid for the frames and lenses per your contract guidelines. For the non-covered items, you were charged 
the difference between the billed amount and the allowed amount. The case file also shows that you received a 
second pair of glasses, which used an existing pair of frames. Your plan only covers one pair of glasses each 
year. This means that you are responsible for the cost of the second pair for glasses. Based on this information, 
we decided that the Plan's rules for coverage have not been met. Therefore, we decided that the Plan does not 
have to further pay for the eyeglasses provided on February 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a device to be placed during surgery (magnetic 
sphincter augmentation system or LINX device) (CPT code(s): L8699 and 43284). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says Medicare says the LINX device is not considered reasonable and medically necessary 
for the treatment of the enrollee's problem. 
 
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 services. Our physician reviewer 
found the medical appropriateness and necessity of hiatal hernia repair and of LINX device placement, and the 
relative risk of proposed surgery, is not supported by the available records. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a device to be placed during surgery (magnetic sphincter augmentation system or LINX 
device) (CPT code(s): L8699 and 43284).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested drug. 
 
  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 
Aranesp is not reasonable and necessary. Our physician reviewer found the Plan requires a trial of Retacrit or 
Procrit before they will approve the requested drug. In this case, the enrollee has not tried and failed Retacrit or 
Procrit. Our reviewer also found that there is no documentation provided indicating that Retacrit or Procrit 
would likely be less effective and/or likely have adverse effects for the enrollee. 
 
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 Aranesp.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tezspire. 
 
You asked the Plan to pre-approve Tezspire. You say that the enrollee has had poor asthma control. You also 
say that the enrollee has never been on another biologic drug. The Plan denied your request. The Plan says the 
enrollee does not meet the criteria for coverage. 
 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 Tezspire. Our reviewer says that 
Tezspire is not reasonable and necessary. Our physician reviewer found there is no indication that the patient 
has tried and failed the required drug(s). Our reviewer also found that there is no indication that the Plan's 
required drug(s) would likely be less effective and/or likely have adverse effects for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tezspire have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Tezspire.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that you need help getting in and out of bed. 
The enrollee's daughter believes the enrollee requires SNF because he has pain and has a Foley catheter. The 
Plan denied your request. The Plan says the enrollee is custodial, and they recommend discharge with home 
health, not daily therapy. The enrollee has no skilled nursing needs. 
 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 admission. Our reviewer says 
that the service is not medically necessary Our physician reviewer found based on the documentation provided, 
it is their opinion that the enrollee does not qualify for SNF coverage. The enrollee does not have documented 
skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating 
household distances and tending to activities of daily living with minimal supervision. The enrollee has an 
available caregiver. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. The enrollees care needs, custodial and intermittent, can, as a 
practical matter, be provided at a lower level of care such as home health services, assisted living, or long-term 
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 admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the skilled nursing facility (SNF) admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to lower your $225 copayment for your observation stay on February 
18, 2022. 
 
You asked the Plan to lower your $225 copayment for an observation stay on February 18, 2022. You say that 
you should only be responsible for the $120 copayment for an emergency room visit. The Plan denied your 
request. The Plan says you must pay a $225 copayment for an observation stay. 
 
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 $225 
copayment for Outpatient Hospital Observation.  
 
 
 
 
 You have been asked to pay a $225 copayment for your observation stay on February 18, 2022. An observation 
stay falls within the Outpatient Hospital Observation 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 lower your 
$225 copayment for your observation stay on February 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 13, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
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 lab 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 lab services provided on July 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on September 13, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says an 
appropriate modifier was not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  In this case, we have confirmed that code 87641 is a column II code to column I code 87150. We have also 
confirmed that code 87150 is a column II code to column I code 87500. This claim has not been billed with an 
appropriate modifier to bypass the edit for each of these code pairs. Based on the claim submitted, Medicare 
billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the lab services 
provided on September 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and electrocardiogram provided on December 
27, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for the office visit and electrocardiogram. You say that this provider is a well-known 
respected cardiologist in your area so you decided to try him out. The Plan denied your request. The Plan says 
these services were provided by a non-contracted provider and were not authorized.  
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 visit and electrocardiogram provided on 
December 27, 2021, by an out-of-network 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 the enrollee's needs would best be served in an 
inpatient rehabilitation setting, and the stay in a skilled nursing facility would likely lead to re-admission. The 
Plan denied your request. The Plan says based on Medicare guidelines and the information we received about 
the enrollee's condition they don't meet the requirements for 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 enrollee was admitted to an acute hospital on 6/14/22 with lumbar spinal 
stenosis with claudication. He is medically stable and comorbid conditions are all stable. There are no complex 
nursing or rehabilitation needs. While the enrollee may benefit from continued physical and occupational 
therapy, his rehabilitation needs can be safely provided in a lower intensity and alternate setting such as in a 
skilled nursing facility or in-home with 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.