Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve non-pneumatic compression devices (K1024, K1033 x2). 
 
You asked the Plan to pre-approve non-pneumatic compression devices. You say that the requested items are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says that rules for coverage for the 
requested items have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary. 
 
In this case, the Plan has denied coverage for services to be rendered by an out-of-network provider, stating 
that the Plan does not have an out-of-network benefit. However, the Plan contract indicates that there is an out-
of-network benefit for durable medical equipment. 
 
Therefore, 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 non-pneumatic compression 
devices. Our reviewer says that the requested items are considered medically reasonable and necessary in this 
case. Our physician reviewer found that the Plan's denial does not appear to challenge the medical necessity of 
the requested compression garments; rather, its denial rationale is based entirely on network issues. Your 
arguments and published evidence for the superiority of your device to stationary alternatives are 
physiologically well-based, and the medical record provided is sufficiently detailed. Therefore, there is no 
controversy regarding the potential medical benefits to the enrollee, and the requested items are definitely 
reasonable and necessary. There is no doubt that Original Medicare would cover the requested devices. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of non-pneumatic compression devices have been met. Therefore, we decided that 
the Plan has to pre-approve non-pneumatic compression devices (K1024, K1033 x2).  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatment (G2067) and the take home 
supply of methadone (G2078) provided on April 10, 2023, by an OON provider.  
 
You asked the Plan to pay for the medication assisted treatment and the take home supply of methadone. You 
say that you are requesting reconsideration of the denied claim. The Plan denied your request. The Plan says 
these 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 the medication assisted treatment (G2067) and the 
take home supply of methadone (G2078) provided on April 10, 2023, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gastric-peroral endoscopic myotomy (G-POEM) with 
the associated inpatient admission. 
 
You asked the Plan to pre-approve the G-POEM procedure. You say that the enrollee has been deemed a good 
surgical candidate for the GPOEM procedure. You also say that this is the superior option for the enrollee. The 
Plan denied your request. The Plan says the clinical value and effectiveness of GPOEM in the setting of 
gastroparesis has not been demonstrated in the peer-reviewed literature. The Plan also says that GPOEM is 
contraindicated with the presence of severe esophagitis and/or coagulation disorder. 
 
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 G-POEM procedure. Our reviewer 
says that the requested G-POEM procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found G-POEM is still a novel technique that while promising is not standard-of-care. 
Further, no objective data was presented with the enrollee's records that demonstrate significant gastroparesis, 
improvement in gastric emptying rates pre- versus post-Botox, nor does available documentation support that 
the symptoms are medically-refractory. The documentation indicates the enrollee is high risk for endoscopic 
sedation. Therefore, the reviewer found that the requested G-POEM procedure is not medically reasonable or 
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 the G-POEM procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve gastric-peroral endoscopic myotomy (G-POEM) with the associated inpatient 
admission.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services for date of service September 2, 
2022, to December 31, 2022. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. 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 September 2, 2022. The NOA was not received by the Plan until January 4, 
2023. 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 the home health services for 
date of service September 2, 2022, to December 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on February 28, 2022. 
 
You asked the Plan to pay for lab tests. You say that this testing was medically necessary. The Plan denied 
your request. The Plan says the Plan did not receive information to determine how the enrollee came to this 
provider, whether the services were performed as billed, or whether the services were medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of lab tests have been met. No supporting 
medical records were submitted. The Plan made multiple attempts to obtain records, but none were provided. 
Without supporting medical records we cannot determine whether these lab services had a valid lab order or 
met Medicare criteria for coverage. Therefore, we decided that the Plan does not have to pay for laboratory 
testing provided on February 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial hospitalization program (PHP).  
You asked the Plan to pre-approve the PHP. You say that you have a lot of crying, anxiety, and nervousness. 
You say that you do not want to leave your house. You say that you have insomnia and are on medication for 
it. You say that you cannot concentrate on anything. You also say that you feel really bad mental and have an 
eating disorder. The Plan denied your request. The Plan says the requested program is 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 the PHP. Our reviewer says that the 
requested partial hospitalization program (PHP) is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the provided records show that you are not showing any dangerousness to 
self or others and is not exhibiting severe psychological or psychiatric impairment requiring this level of care. 
You were not showing any perceptual disturbance, psychosis or aggressive behaviors. Therefore, the reviewer 
found that the partial hospitalization program is not medically reasonable or 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 the PHP have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a partial hospitalization program (PHP).
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance services (A0428) provided on December 2, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this is a duplicate 
claim. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that this is a duplicate claim. However, the Plan has not 
provided documentation showing that this code was previously paid for the date of service in question. Without 
supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to 
pay for the ambulance services (A0428) provided on December 2, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 13, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on April 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a laser vitreolysis. 
 
You asked the Plan to pre-approve a laser vitreolysis. You say that this treatment has greatly improved 
previous problems dramatically. The Plan denied your request. The Plan says this is not a covered procedure. 
 
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 a laser vitreolysis. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found laser vitreolysis has been suggested to be a treatment for floaters. This treatment is 
not considered a standard treatment by the majority of retina specialists within the United States. 
 
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 laser vitreolysis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a laser vitreolysis.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0483) provided on March 6, 2023. 
 
You asked the Plan to pay for drug testing. You say that this testing was medically necessary and is supported 
in the medical record. The Plan denied your request. The Plan says there is insufficient documentation in the records to support that these services were specifically requested by the enrollee's physician and were 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of drug testing have been met. 
Specifically, the records provided do not include a physician order with a specific list of drugs requested for 
testing. Without this information, we cannot verify that the services provided were requested by the enrollee's 
treating physician and were medically necessary. Therefore, we decided that the Plan does not have to pay for 
drug testing (G0483) provided on March 6, 2023.
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 You say that the enrollee is not safe at home. You 
also say that the hospital has been doing whatever they can to assist the enrollee, and they need 24 care 
assistance. The Plan denied your request. The Plan says 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 enrollee is medically stable and did not need a physical medicine and 
rehabilitation physician's supervision 3 times a week in an IRF. There are no acute rehabilitation nursing needs 
identified or documented. At the current mobility level, the enrollee does not need intensive therapies 
consisting of at least 3 hours of therapy per day at least 5 days per week with a  multidisciplinary approach in 
an IRF. Our reviewer found that the documentation does not support necessity for admission to an IRF. The 
complexity of the enrollee's medical, rehabilitation, and nursing needs (combined complexity) does not require 
an acute hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. Our 
physician reviewer also found that the enrollee's rehabilitation needs can be safely provided in an alternate and 
low intensity setting such as in a skilled nursing facility or in-home with services.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve the home health aide services. You say that a home health aide helps you 
stay at home and out of a nursing home. The Plan denied your request. The Plan says the information provided 
does not support the need for a home health aide. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 home health aide services. Our reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found the 
enrollee has not been recently hospitalized and there are not noted acute changes in her medical conditions that 
would require skilled nursing care. The appellant's level of mobility is stable, and her progress has plateaued as 
there is a lack of objective documentation regarding her progress with therapy. 
 
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 home health aide services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home health aide services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you are appealing this denial. The Plan denied your 
request. The Plan says a SNF admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing provided on May 10, 2023, billed with 
codes 87471, 87481, 87493, 87500, 87529, 87561, 87563, 87540, 87641, 87651, 87653 and 87798. 
 
You asked the Plan to pay for the panel testing billed. You say that this test 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 panel testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the panel testing provided on 
May 10, 2023, billed with codes 87471, 87481, 87493, 87500, 87529, 87561, 87563, 87540, 87641, 87651, 
87653 and 87798.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the diagnostic computed tomography (CT) 
scan of the chest provided on April 14, 2023.  
 
You asked the Plan to waive the cost sharing for the diagnostic chest CT scan. You say that you were told that 
this testing would be covered at no cost. You feel that you are being incorrectly charged.  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 diagnostic imaging, including CT scans. The rules indicate that LDCT screening is covered only 
for enrollees with no symptoms of lung cancer. 
 
Review of the records related to this case shows that on a prior LDCT scan on October 11, 2022, there were 
findings of a new pulmonary nodule. Though this may not be representative of lung cancer, a pulmonary 
nodule is a sign of potential lung cancer. As such, this means you are no longer considered asymptomatic, and 
the lung cancer screening with no cost sharing does not apply. The imaging performed was, therefore, not 
LDCT, but rather a full diagnostic CT scan. 
 
You have been asked to pay $125.95 for the diagnostic chest CT scan, which is less than the applicable $275 
copayment. This item/service falls within the diagnostic imaging, including CT scans 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 cost sharing for the diagnostic computed tomography (CT) scan of the 
chest provided on April 14, 2023.