Persius/hicric huggingface dataset:
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 needs this care to regain independence. 
The Plan denied your request. The Plan says medical records do not support the need for an IRF admission and, 
the enrollee needs can be provided at another setting.  
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. There is not a reasonable expectation that the enrollee 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the meningococcal recombinant protein and outer membrane 
vesicle vaccine (90620), and meningococcal conjugate vaccine (90734) provided on May 2, 2023. 
 
You asked the Plan to pay for the vaccine services. You say that you needed these vaccines. You say that the 
public vaccination centers and hospitals do not have them. You also say that you cannot afford to pay for these. 
The Plan denied your request. The Plan says these services are not covered under your Part B benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine services. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine 
services. Therefore, we decided that the Plan does not have to pay for the meningococcal recombinant protein 
and outer membrane vesicle vaccine (90620), and meningococcal conjugate vaccine (90734) provided on May 
2, 2023.  
 Benefits for the vaccine services may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided by an in-network 
provider on July 12, 2022, and March 13, 2023. 
 
You asked the Plan to waive the copayment for the office visits. You say that you do not understand the cost 
sharing. 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 $35 
copayment for in-network provider and professional services provided in a specialists office. 
 
 You have been asked to pay a $70 copayment for the office visits ($35 copayment x 2 services = $70). These 
items/services fall within the physician/practitioner services, including doctor's office visits 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 waive the copayment for the office visit provided by an in-network provider on July 
12, 2022, and March 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
  You asked the Plan to pre-approve a home ventilator system. You say that the enrollee is unable to tolerate a 
CPAP. You say that the enrollee is using the Life2000 ventilator every day and has less shortness of breath and 
can walk longer on the treadmill at pulmonary rehab. The Plan denied your request. The Plan says a home 
ventilator is not medically necessary for this patient because their needs can be met with an alternative device 
such as a BiPAP device with average volume-assured pressure support (AVAPS).  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the enrollee 
has severe COPD and is being evaluated for lung transplantation. The Life2000 system is not a true ventilator 
because it is not capable of providing full ventilatory support. Also, it is intended to be used during activity, 
and there is inadequate evidence that it is beneficial in the treatment of any chronic lung disease. Therefore, the 
Life200 system is not 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 a home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service June 29, 2023. 
 
You asked the Plan to pay for the billed testing. You say that the testing was necessary to assist in treatment 
and diagnosis for the enrollee. The Plan denied your request. The Plan says the test is not covered. 
 
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 the panel testing provided is not supported in the medical records. The records show that the 
enrollee has stage II cancer, not advanced cancer as required. The diagnosis code C76.0 is not among those that 
support medical necessity. Additionally, the records do not sufficiently document that the testing is expected to 
influence treatment of the enrollees condition Based on this information, we decided that Medicare rules for 
coverage of the billed testing have not been met. Therefore, we decided that the Plan does not have to pay for 
the lab testing billed for date of service June 29, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 36 trips for routine transportation. 
 
You asked the Plan to pre-approve the additional trips. You say that the additional trips are medically necessary 
for the enrollee to continue with their appointments. The Plan denied your request. The Plan says the enrollee 
has already used up their routine transportation benefit for the year. 
 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. The Plan covers a maximum of 36 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve an additional 36 trips for routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99291 and 95819 for date of service 
February 2, 2023. You asked the Plan to pay for procedure codes 99291 and 95819. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also say that technical 
components must be billed by the facility where the enrollee was an inpatient or outpatient and are not 
separately payable to the lab. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the medical records 
submitted do not include a critical care evaluation and management note for the billed date of service. 
The records indicate that this service was provided to the enrollee while an inpatient. Per the Physician Fee 
Schedule, there is a Professional/Technical indicator of 1 for CPT code 95819. This means there is both a 
professional and technical component for the CPT code. In this case, an appropriate modifier to indicate the 
professional component has not been billed with CPT code 95819. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 99291 and 95819 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 99291 and 95819 for date of service February 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered arm prosthesis (L8702). 
 
You asked the Plan to pre-approve the powered arm prosthesis. You say that this item is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 the powered arm prosthesis. Our 
reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the MyoPro orthosis is not the standard of care for this patient's brachial plexus 
condition or in widespread use for this patient's condition based on scientific evidence. 
 
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 powered arm prosthesis have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a powered arm prosthesis (L8702).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a breath hydrogen or methane test (91065). 
 
You asked the Plan to pre-approve a breath hydrogen or methane test. You say that you have gastric distress on 
a chronic basis with bloating, diarrhea and pain, also belching. The Plan denied your request. The Plan says 
you do not meet criteria because the test requested is not for a covered indication, to detect lactose 
malabsorption. 
 
The Plan follows Medicare rules. Medicare rules say that Lactose breath hydrogen to detect lactose 
malabsorption is the covered breath test.  
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 a breath hydrogen or methane test. Our 
reviewer says that the criteria for coverage are not met for the service under review. Our physician reviewer 
found you complain of bloating, belching, epigastric pain, and diarrhea. Your provider has proposed lactose 
breath testing next to rule out SIBO (small intestinal bacterial overgrowth). Our reviewer found that this 
indication falls outside the limits of coverage for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a breath hydrogen or methane test have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a breath hydrogen or methane test (91065).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Rituxan (J9312). 
 
You asked the Plan to pre-approve Rituxan. You say that given the patient's history, condition, and the 
published literature, you believe the treatment of Granulomatous vasculitis is warranted, appropriate, and 
medically necessary. The Plan denied your request. The Plan says that this request is not medically necessary. 
 
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 Rituxan. Our reviewer says that 
Rituxan is medically reasonable and necessary. Our physician reviewer found the review indicates that Rituxan 
is indicated for the treatment of granulomatosis with polyangiitis (GPA) (Wegener's granulomatosis), 
microscopic polyangiitis (MPA), Churg-Strauss, or pauci-immune glomerulonephritis. Rituxan is indicated for 
people ages 2 years and above with granulomatosis with polyangiitis (GPA) (formerly known as Wegener's 
granulomatosis) and microscopic polyangiitis (MPA). The review has determined that the requested use of 
Rituxan (J9312) is FDA-approved for the patients diagnosis. Our reviewer found that its use is supported by 
one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid 
Services (CMS) approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Rituxan have been met. Therefore, we decided that the Plan has to pre-approve 
Rituxan (J9312).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and CGM sensor. 
 
You asked the Plan to pre-approve a continuous glucose monitor (CGM) and CGM sensor. You say that you 
would like to request reconsideration of the denied claim and that the services requested are medically 
necessary. The Plan denied your request. The Plan says the services requested are not covered benefits. 
 The Plan must follow Medicare rules. Medicare rules say that, in no case can the RUL of equipment be less 
than 5 years. The rules also say that replacement due to wear is not covered during the RUL of the equipment.  
 
The item being requested shows to be for replacement of an identical or nearly identical item, due to wear. The 
case file shows that the existing equipment is less than 5 years old. This means that replacement of this 
equipment due to wear is not covered at this time. The requested sensors are not covered. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and CGM sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the end-stage regnal disease (ESRD) treatment provided 
from June 1, 2023, to June 29, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the ESRD treatment. You say that you are a Medicare certified facility. You say 
that the enrollee's plan is a Medicare Advantage plan. You also say that the services were medically necessary. 
The Plan denied your request. The Plan says services received out-of-network are 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 in this case is not a network provider with the Plan. The referring provider is not a network 
provider either. 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 service at issue. We found no exception that would require the 
Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the end-stage regnal 
disease (ESRD) treatment provided from June 1, 2023, to June 29, 2023, by an out-of-network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  a CGM sensor. 
 You asked the Plan to pre-approve  a CGM sensor. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that that the CGM supplies are not covered if they 
will not be used in conjunction with a covered CGM receiver. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a CGM sensor have not been met. Therefore, we decided that the Plan does not have to preapprove 
a CGM sensor.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic mammography (77066), breast ultrasound 
(76642), and breast tomosynthesis (77062) provided on May 4, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient services. You say that you do not agree with this denial. You say 
that based on the enrollee's benefit profile the rendered services are covered and reimbursable. The Plan denied 
your request. The Plan says prior authorization was not obtained. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the diagnostic mammography (77066), breast ultrasound (76642), and breast 
tomosynthesis (77062) provided on May 4, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on June 30, 2023, billed with 
codes 87481, 87491, 87563, 87640, 87653, 87798, 87641 and 87500. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was 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 a 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 a laboratory 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 laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on June 30, 2023, billed with codes 87481, 87491, 87563, 87640, 87653, 87798, 87641 and 
87500.
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 services are medically necessary for the enrollee 
to receive the services needed to return to their baseline. The Plan denied your request. The Plan says the 
enrollee does not meet the 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 the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 25, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the outpatient service. You say that the claim should be paid. The Plan denied 
your request. The Plan says prior authorization was not obtained. 
 
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 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 provided on May 25, 2023, by an 
out-of-network (OON) provider.