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

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from February 1, 
2022, to February 22, 2022. 
 You asked the Plan to pay for the SNF care. You say that the services which the enrollee required and received 
are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition no 
longer required daily skilled services at an inpatient SNF level of care. 
 
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 pay for the SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/or skilled therapy on 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) care provided from February 1, 2022, to February 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CTA, a special kind of picture of the blood vessels in 
your abdomen or stomach area (CPT code 75635). 
 
You asked the Plan to pre-approve the CTA. You say that the service is necessary. The Plan denied your 
request. The Plan says the service is not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CTA. Our physician reviewer found 
the provided record does not document physical assessment of pulses. The provided records do not indicate the 
medical necessity or reasonableness, as defined by Medicare rules, of the requested service. The elements of 
the coverage criteria are not satisfied. 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 CTA have not been met. Therefore, we 
decided that the Plan does not have to pre-approve CTA, a special kind of picture of the blood vessels in your 
abdomen or stomach area (CPT code 75635).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea 2MG/0.05ML syringe (CPT code J0178). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says there is no documentation in the enrollee's records to indicate that the enrollee has 
tried and failed the preferred medication. 
 
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 the medication. Our physician reviewer 
found the Plan requires a trial of drug Avastin before they will approve the requested drug. In this case, the 
enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the 
Plans required drug(s) 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Eylea 2MG/0.05ML syringe (CPT code J0178).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Simponi Aria 12.5 mg/mL intravenous solution (CPT 
code J1602). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says information from the enrollee's provider does not show that they have tried either 
medication and the enrollee's provider has not demonstrated that it is medically necessary to make an exception 
for the enrollee. 
 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 the medication. Our physician reviewer 
found the Plan requires a trial of drug Inflectra or Renflexis before they will approve the requested drug. In this 
case, the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating 
that the Plans required drug(s) 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Simponi Aria 12.5 mg/mL intravenous solution (CPT code J1602).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code  billed for date of service July 15, 2021. 
 
You asked the Plan to pay for procedure code . You say that this should be paid for. 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  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  
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code  billed for date 
of service July 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
to get to your doctor appointments. The Plan denied your request. The Plan says this request exceeds your 
benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case.  
 
We looked at your request, the records in the case file, and the rules. The 51st trip and beyond is not a covered benefit. Your 2022 EOC states that you are covered for fifty (50) one-way, non-emergency trips to Plan-
approved locations within the Plan service area. Therefore, we decided that the Plan does not have to pre-
approve additional routine transportation trips.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service June 18, 
2022 to July 15, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service June 18, 2022 to July 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance services provided to the enrollee on May 1, 
2021. 
 
You asked the Plan to pay for the services. You say that s an emergency transport, a prior authorization was not 
required. The Plan denied your request. The Plan says pre-certification/authorization/notification/pre-treatment 
was absent. 
 The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found that the 
documentation does support that the patient suffers from an illness or injury that contraindicates transportation 
by any means other than ambulance. The documentation does not support that the patient's condition was such 
that the time needed to transport a patient by ground, or the instability of transportation by ground, posed a 
threat to the patient's survival or seriously endangered the patient's health. he documentation does not support 
that the transferring hospital did not have adequate facilities to provide the medical services needed by the 
patient. There was no indication from the provided documentation that the patient could not be safely and 
effectively treated from where they transferred from. 
 
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 pay for air ambulance services provided to the enrollee on May 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the golf services purchased between April 1, 2022, to April 
30, 2022. 
 
You asked the Plan to pay for the golf services. You say that you were unaware the fitness kit would take place 
of your reimbursement. The Plan denied your request. The Plan says you placed an order for a fitness kit 
through the Plan in April 2022, which exceeded your monthly fitness reimbursement benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers qualifying 
fitness expenses up to $50 per month, or you can use your monthly allowance to order fitness equipment. 
 
The Plans rules for coverage of gym benefits have not been met because the record shows you purchased 
fitness equipment which exhausted your monthly fitness benefit allowance. Therefore, we decided that the Plan 
does not have to pay for the golf services purchased between April 1, 2022, to April 30, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing evaluation services by 
physician or other qualified health care professional (96132) and psychological or neuropsychological test 
administration and scoring by technician (96138). 
 
You asked the Plan to pre-approve neuropsychological testing evaluation and administration. You say that the 
enrollee requires a NeuroTrax memory test due to a worsening memory. You also say that this test will help 
rule out Dementia as a cause of the enrollee's symptoms. The Plan denied your request. The Plan says the 
information provided does not support the request for neuropsychological testing. 
 
The Plan follows Medicare rules. Medicare rules say that the treatment plan must state the type, amount, 
frequency, and duration of the services to be furnished and indicate the diagnoses and anticipated goals. 
 
 
  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 neuropsychological testing evaluation 
and administration. Our reviewer says that neuropsychological testing evaluation and administration is not 
reasonable and necessary. Our physician reviewer found in this case, a technician will not administer two or 
more psychological or neuropsychological tests and score them, as this testing is automated, and is 
administered via an electronic platform that provides automated results and reports. In addition, a provider, a 
physician or other qualified healthcare professional, will not spend up to one hour administering 
neuropsychological tests, including time spent face-to-face with the enrollee in performing the tests, 
interpretation of the outcome, and preparation of the report. Our reviewer found that consequently the current 
procedural terminology (CPT) codes are not appropriate for this testing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing evaluation and administration have not been met. 
Therefore, we decided that the Plan does not have to pre-approve neuropsychological testing evaluation 
services by physician or other qualified health care professional (96132) and psychological or 
neuropsychological test administration and scoring by technician (96138).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for infusion services provided from June 9, 
2020, to June 23, 2020. 
 
You asked the Plan to waive the copayments for the infusion services. You say that you had met your 
maximum out-of-pocket expenses for the year. 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 $275 
copayment for surgery or other services provided to you at an outpatient hospital.  
 
You have been asked to pay $175.58 for each infusion, which is less than the $275 copayment per the EOC. 
This item/service falls within the surgery or other services provided to you at an outpatient hospital benefit 
category. Please note that cost sharing is applied to the out-of-pocket maximum in the order the claims are 
processed by the Plan. The total for all services is $351.16. 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 copayments 
for infusion services provided from June 9, 2020, to June 23, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on November 11, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for genetic testing. You say that you would like the original determination 
reconsidered and covered as medically necessary. The Plan denied your request. The Plan says this provider 
did not obtain a prior authorization prior to services being rendered. 
 
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 genetic testing provided on November 11, 2021, 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from July 5, 2021, to July 7, 
2021, as billed with Diagnosis Related Code (DRG) 178. 
 
You asked the Plan to pay for inpatient care billed with DRG 178. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 178 is not appropriate as the diagnosis of pneumonia due to other gram-negative bacteria (J15.6) is not supported in the 
medical record. The Plan argues that DRG 194 is more appropriate in this case. 
 
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. 
 
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 inpatient care billed with DRG 178. Our 
reviewer says that the diagnosis of pneumonia due to other gram-negative bacteria (J15.6) is not supported in 
the medical record for this inpatient admission. Our physician reviewer found that the enrollee presented with 
complaints of shortness of breath, cough, congestion, and weakness. Past medical history included abdominal 
hernia, bipolar disorder, hyperlipidemia, and hypertension. The initial chest x-ray noted left upper lobe 
consolidation concerning for pneumonia. A computed tomography (CT) angiogram of the chest was also 
obtained which showed no evidence of pulmonary embolism. The enrollee was diagnosed with left upper lobe 
pneumonia and was placed on Ceftriaxone and Azithromycin. While the discharge summary indicated that 
pneumonia was likely gram-negative, the clinical evidence did not support a gram-negative pneumonia. The 
review has determined that the medical records did not support the billing of pneumonia due to other gram-
negative bacteria (J15.6). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 178 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from July 5, 2021, to July 7, 2021, as 
billed with Diagnosis Related Code (DRG) 178.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on June 8, 2022. 
 
You asked the Plan to pay for the lab services. You say that a more complex drug screening was provided. The 
Plan denied your request. The Plan says that the code was billed without an accompanying narrative. 
 
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. 
 
We looked at the file and the rules. The reference the Plan uses in their decision does not include the code at 
issue. The Plan does not provide Medicare rulings/citations to support their decision. The Plan has not made 
reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your 
request.  Therefore, we decided that the Plan has to pay for the laboratory services provided on June 8, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia service provided on May 26, 2022, by an OON 
provider. 
 
You asked the Plan to pay for the anesthesia service. The Plan denied your request. The Plan says the out-of-
network services 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 anesthesia service provided on May 26, 2022, by 
an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Lite Test strips (CPT code K0553). 
 You asked the Plan to pre-approve the strips. You say that the strips are necessary. The Plan denied your 
request. The Plan says they have not received information from either the enrollee or their physician to indicate 
that any of the conditions, or any other reason the enrollee cannot use the covered brand pertain to 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 strips. Our physician reviewer 
found the provided records do not document the medical necessity of the requested product. The record 
provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the 
requested service. The elements of the coverage criteria are not satisfied. 
 
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 strips have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Freestyle Lite Test strips (CPT code K0553).