Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 You asked the Plan to pre-approve Prolia. You say that due to the enrollee's medical history, oral 
bisphosphonates need to be avoided. The Plan denied your request. The Plan says the enrollee has not tried and 
failed any of the preferred drugs. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed the preferred drugs, pamidronate and zoledronic acid. The reviewer found 
that there is no documentation provided indicating that the plans required drugs would likely be less effective 
and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that the step therapy criteria 
have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
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 admission to an IRF is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an IRF. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial nursing facility care provided on September 27, 2022. 
 
You asked the Plan to pay for initial nursing facility care. You say that the claim was filed timely. The Plan 
denied your request. The Plan says that the Plan tried to inform the provider of the members primary 
insurance; however, all calls were unanswered. Until the Plan receives the members primary insurances 
explanation of benefits (EOB) for the claim, the Plan is unable to process the claim. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has attempted to 
notify the provider of the need for the EOB from the enrollees primary insurer. As the secondary insurer, the 
Plan cannot be held responsible for initial nursing facility care until the primary insurer has denied the claim 
for these services. Therefore, we decided that the Plan does not have to pay for initial nursing facility care 
provided on September 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gauze (A6223) non-waterproof tape (A4450) and specialty 
absorptive dressing (A6252) provided October 15, 2022. 
 
You asked the Plan to pay for the wound care supplies. You say that you have uploaded the proof of delivery 
document that has a FedEx logo on it to the availability portal, which is the delivery confirmation document. 
The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.   
The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. The supplier did not provide office notes to 
support the subsequent ordering of wound care supplies. 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 gauze (A6223) non-waterproof tape (A4450) and specialty absorptive dressing (A6252) provided 
October 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses provided on November 5, 2022. 
 
You asked the Plan to pay for the eyeglasses. The Plan denied your request. The Plan says per the members 
benefits, the plan coverage is limited to 1 pair of lenses and frames every 2 years. The Plan issued 
payment for the first eyewear purchased on date of service April 24, 2021. Therefore, second eyewear received 
from supplier on November 05, 2022, denied correctly. 
 Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services every 2 years. 
 
We looked at the file and the Plan's rules. The file shows you have exceeded the eyewear benefit. Based on this 
information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we 
decided that the Plan does not have to pay for eyeglasses provided on November 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71271 billed for date of service December 
28, 2022.  
 
You asked the Plan to pay for procedure code 71271. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 71271 is bundled into payment for code 
71250. 
 
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 71271 is a column II code to column I code 71250 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 71271 billed for date of service December 28, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 18, 2022, to May 
17, 2022. 
 You asked the Plan to pay for the home health services. You say that you have submitted the required NOA. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is February 16, 2022. The NOA was not received by the Plan until August 10, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from April 18, 2022, to May 17, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on 
October 18, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment, no transport. You say that you were in an 
accident and the ambulance was called to the scene. You say that you declined the transport because you did 
not think your hip was hurt enough to go to the hospital although the next day you did go to the emergency 
room. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transportation benefit 
and without a transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 18, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
provided on October 18, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on January 5, 2023. 
 
You asked the Plan to pay for the medical services. You say that the diagnosis codes were billed correctly. The 
Plan denied your request. The Plan says you billed an inappropriate pair of diagnosis codes. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnosis codes with an Excludes1 note indicates 
that the code excluded should never be used at the same time as the code above the Excludes1 note. 
 
In this case, you billed this claim with diagnoses of F30.2 and F31.9. Code F30.2 is an Excludes1 code under 
code F31.9, so these two diagnoses cannot be billed together. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided on January 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with code 87631 for date of service 
September 26, 2022. 
 
You asked the Plan to pay for the lab services. You say that the medical records support payment of this code. 
The Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services billed with code 87631 
for date of service September 26, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 11, 2022, to 
September 7, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you do not believe this claim 
should have been denied in full. The Plan denied your request. The Plan says the claim has not been billed with 
the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from August 11, 2022, to 
September 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 13, 2022, to 
July 6, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this claim should not have 
denied in full.  This claim should have just had a late NOA penalty attached to it. The Plan denied your request. 
The Plan says the claim has not been billed with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from June 13, 2022, to July 6, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for code 99498 billed for date of service May 9, 2022. 
 
You asked the Plan to pay for code 99498. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says this code was not billed with the required primary care 
(99497). 
 
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 code 
99498 is an add-on code and has not been billed with an appropriate primary procedure code. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for code 99498 billed for date of service May 9, 2022.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a 
lower level of care such as a skilled nursing facility, home health care, or outpatient services. 
 
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 for a stroke and was transferred to skilled nursing on May 
22, 2023. The enrollee's medical problems are stable, and there are no complex nursing or rehabilitation 
needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthopedic slippers purchased on December 20, 2022. 
 
You asked the Plan to pay for the items. You say that you purchased orthopedic slippers. You also say that you 
have to wear orthopedic footwear for your feet. The Plan denied your request. The Plan says the items are not 
covered under the supplemental benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the items have not been met. Specifically, the Evidence of Coverage indicates the items and 
services covered under the supplemental benefit. Orthopedic footwear is not included. Therefore, we decided 
that the Plan does not have to pay for the orthopedic slippers purchased on December 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on July 13, 2022. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan 
was the secondary payer on this date of service. The primary payer will need to review the services for 
payment consideration before the Plan can consider the claim for payment as the secondary payer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has notified the 
provider to coordinate benefits. As the secondary insurer, the Plan cannot be held responsible for the 
physician's services until the primary insurer has denied the claim for these services. Therefore, we decided that 
the Plan does not have to pay for physician's services provided on July 13, 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 LTACH is medically necessary. The 
Plan denied your request. The Plan says the LTACH is not medically necessary, and the enrollee's needs can be 
met in a lower level of care such as a skilled nursing facility, nursing facility, outpatient setting or home care. 
 
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 appears to be improving at this time and requires additional short-term 
acute care services that can safely be provided at the current facility until more stable and appropriate for a 
lower level of care. The enrollee does not require services at the LTACH that are not already available at the current facility.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.