Persius/hicric huggingface dataset:
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 as the enrollee exceeds the criteria for an appropriate LTACH admission. 
The Plan denied your request. The Plan says the LTACH services you are requesting 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 the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. There are no services available at the LTACH that 
the enrollee requires that are not available at the health care setting being offered by the Plan. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services provided on August 19, 
2022. 
 
You asked the Plan to pay for evaluation and management services. You say that this was the only provider 
available. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for evaluation and 
management services provided on August 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xywav (J8499). 
 
You asked the Plan to pre-approve Xywav. You say that the enrollee's symptoms continue to worsen. The Plan 
denied your request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part B. 
 
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 Xywav (J8499).   
Benefits for Xywav 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from February 5, 
2022, to May 2, 2022. 
 You asked the Plan to pay for SNF care. You say that these services were pre-approved and were reported 
correctly. The Plan denied your request. The Plan says the necessary HIPPS rate code is missing from this 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that all SNF Part A inpatient services are paid under a prospective payment system (PPS). This 
involves payment based on a Health Insurance Prospective Payment System (HIPPS) rate code. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SNF care have not been met. Specifically, this claim is missing the necessary HIPPS rate code for 
SNF care. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) care 
provided from February 5, 2022, to May 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. You say that the enrollee currently has a feeding tube, and the 
alendronate they have been on since 2019 cannot be crushed to be taken through the feeding tube. You also say 
that you feel Prolia will be more effective than reclast in helping to reduce fracture risk for the enrollee. The 
Plan denied your request. The Plan says given there was not a treatment failure on an oral bisphosphonate and 
zoledronic acid has not been ruled to be ineffective or harmful to the enrollee, it is recommended to uphold the 
denial. 
 
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 Prolia. Our reviewer says that the 
enrollee does not meet the coverage criteria for Prolia. Our physician reviewer found the provided records do 
not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to, or would have an adverse effect from the Plan's preferred 
step one alternative. Our reviewer found that the elements of the coverage criteria are not satisfied. Our 
physician reviewer also found that the requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that the requested drug is necessary for the enrollee. The 
Plan denied your request. The Plan says that the requested use is not approved by the FDA for the enrollee's 
condition. 
 
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 Evenity. Our reviewer says that the 
requested drug Evenity is medically necessary. Our physician reviewer found the provided documentation 
indicates the enrollee has a diagnosis of osteoporosis. The documentation indicates the enrollee is at high risk 
for fracture. The reviewer found that the enrollee tried an oral bisphosphonate after a previous fall but had to 
discontinue it due to gastrointestinal side effects. Therefore, the reviewer found that the requested use of 
Evenity is medically reasonable and 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 Evenity have been met. Therefore, we decided that the Plan has to pre-approve 
Evenity.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service August 5, 
2022. 
 
You asked the Plan to pay for procedure code 86077. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service August 5, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency care or pay for the drugs 
you were provided from December 8, 2022, to December 10, 2022. 
 
You asked the Plan to waive the copayment and to pay for the drugs. The Plan denied your request. The Plan 
says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 
copayment for emergency services. The rules also say that Medicare Part B generally does not pay for self-
administered drugs. 
 
Review of the file shows that you were provided emergency care. You have been asked to pay a $120 
copayment for these services. This service falls within the emergency services 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. Additionally, 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 waive the copayment for the emergency care and pay for the drugs you were 
provided from December 8, 2022, to December 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 13, 2022, billed with 
codes 81194, 81210, 81235, 81272, 81275, 81276, 81292, 81295, 81298, 81301, 81311, 81317 and 81321. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 13, 2022, billed with codes 81194, 81210, 81235, 81272, 81275, 81276, 81292, 81295, 81298, 81301, 
81311, 81317 and 81321.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT). 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee has a history of 
multiple metastases and the plan is to treat a resected tongue/base of tongue lesion with SBRT. SBRT is not the 
standard of care for this indication outside of re-irradiation of head and neck cancer. The services are 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 stereotactic body radiation therapy (SBRT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). You asked the Plan to pre-approve SSBCI benefits. You say that you need these benefits. The Plan denied your 
request. The Plan says the criteria for eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination. 
The rules also say that for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, your provider has not provided sufficient 
information to show that you have an eligible condition that meets all the required criteria. Therefore, we 
decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 85060 billed for date of service November 
21, 2022. 
 You asked the Plan to pay for procedure code(s) 85060. You say that this procedure was rendered in an 
appropriate place of service. The Plan denied your request. The Plan says this code is included in the facility 
payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 85060. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 85060. Based on this information, 
we decided that Medicare rules for coverage of procedure code 85060 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 85060 billed for date of service November 21, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is too complex with mild 
progression for skilled nursing facility and requires extended, acute care level interventions provided by 
complex care trained staff, interdisciplinary treatment and team driven rehabilitation to resume reconditioning 
and improvement. The Plan denied your request. The Plan says the long-term acute care hospital service 
requested is not supported based on the records we received, the enrollee's records meet guidelines for care in a 
skilled nursing facility or an inpatient rehabilitation facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not require services at a long-term acute care hospital that are not 
available at the current acute care hospital. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 01402 and 64447 billed for May 13, 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 01402 is not supported and 64447 is inclusive to another billed 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. 
 
In this case, the CPT Code Manual definition of code 01402 is anesthesia for open or surgical arthroscopic 
procedures on knee joint; total knee arthroplasty. 
 
We find that CPT code 01402 is not supported in the medical record. Specifically, the records show that 
anesthesia for open or surgical arthroscopic procedures on knee joint, not otherwise specified, was performed 
and there is a more appropriate code for these services. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. 
 
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 64447 
is a column II code to column I code 01402. Given that code 01402 is not supported, code 64447 cannot be 
approved as it is a column II code to column I code 01402. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 01402 and 64447 billed for May 
13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 sensor. 
 
You asked the Plan to pre-approve a FreeStyle Libre 2 sensor. The Plan denied your request. The Plan says the 
provider was asked if the enrollee was on insulin and checked no on the box. The Plan also says there are no 
paid claims in the pharmacy system for insulin, and the enrollee is on glipizide and metformin. 
 
 
 
 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 indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
FreeStyle Libre 2 sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
FreeStyle Libre 2 sensor.
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 stating the enrollee would benefit from inpatient rehabilitation. The Plan denied your request. 
The Plan says the IRF services requested do not meet the requirements for approval. 
 
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 the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99223, 99233) provided on December 17, 2021, 
and December 18, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are 
inappropriate for the billed place of service. 
 
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 find that payment for CPT codes 99223 and 99233 is not supported in the medical record. Specifically, the 
claim was billed with an outpatient POS code (22). It is inappropriate to bill an outpatient place of service with 
inpatient evaluation and management codes. 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 pay for the 
services (99223, 99233) provided on December 17, 2021, and December 18, 2021.