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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does 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 that the health Plans denial should be upheld. The enrollee does not require the 
intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per 
week of rehabilitative services and regular physician evaluation. The enrollees care needs can be met at a 
lower 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder detect test (0012M) provided on November 
15, 2022. 
 
You asked the Plan to pay for the Cxbladder detect test. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered.   
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder detect test have not been met. Therefore, we decided 
that the Plan does not have to pay for the Cxbladder detect test (0012M) provided on November 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99239 for date of service September 24, 
2022. 
 
You asked the Plan to pay for procedure code 99239. 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. 
 
In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the documentation submitted 
did not include documentation of hospital discharge day management for more than 30 minutes for the billed 
date of service.  Based on this information, we decided that Medicare rules for coverage of procedure code 99239 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 99239 for date of service 
September 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fulphila (Q5108). 
 
You asked the Plan to pre-approve Fulphila. The Plan denied your request. The Plan says the requested 
drug/regimen is not being prescribed for a medically accepted indication. 
 
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 Fulphila. Our reviewer says that 
Fulphila is not medically reasonable and necessary for the enrollee. Our physician reviewer found the requested 
use of Fulphila is not FDA-approved for the enrollees diagnosis. The use is not 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. Our reviewer also found that the use is not listed as not indicated, not supported or 
not recommended in any of the compendia.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Fulphila have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Fulphila (Q5108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested device should be considered 
for coverage in the enrollee's treatments. It will provider the enrollee with the ventilatory support she requires 
and will be used 
as a ventilator. The Plan denied your request. The Plan says the request is not medically necessary because the 
records show the ordered settings for the noninvasive ventilator can be delivered by a bi-level PAP machine 
with AVAPS capability. 
 
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. 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. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has COPD of moderate 
severity and pulmonary hypertension. There is no evidence of chronic CO2 retention. The Life2000 system is 
not a true ventilator because it is not capable of providing full ventilatory support. 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. 
 
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 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  CxBladder testing (0012M) provided November 7, 20122. 
 
You asked the Plan to pay for  the laboratory service. You say that the evidence supporting the use of 
CxBladder Detect as a medically necessary diagnostic service is well established and affirmed by Medicare. 
The Plan denied your request. The Plan says this testing does not meet the coverage requirements. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for  CxBladder testing (0012M) provided November 7, 20122.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is currently in the hospital. 
The enrollee will benefit from and improve with LTACH care with an expected length of stay greater than 25 
days. The Plan denied your request. The Plan says the enrollee does not meet criteria for admission into an 
LTACH. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where she is currently receiving 
care. There are no services available at the LTACH that the enrollee requires that are not available at the health 
care setting being offered by the health plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lomotil. 
 
You asked the Plan to pre-approve the medication. You say that Lomotil is medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lomotil.   
Benefits for the medication 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a rollator walker to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve a lightweight rollator walker. You say that you would like to purchase the 
requested walker through Amazon. The Plan denied your request. The Plan says the requested provider is not 
part of the Plan's preferred network and not uniquely qualified to provide durable medical equipment (DME) to 
you. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a rollator walker to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is medically stable to be 
transferred to LTACH level of care. The Plan denied your request. The Plan says an LTACH admission is not 
medically necessary, and the enrollee's needs can be met in the current hospital setting.  
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. The health plan has approved ongoing care in 
the current acute care 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test (81479) provided on November 22, 2022. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says the requested test does not meet requirement for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. The DEX database shows that PrismRA is not covered. Based on this information, we decided that Medicare rules for coverage of the PrismRA test have not been met. Therefore, 
we decided that the Plan does not have to pay for the PrismRA test (81479) provided on November 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter edge-to-edge repair (TEER). 
 
You asked the Plan to pre-approve TEER. You say that this procedure is needed because the patient is still 
having symptoms. The Plan denied your request. The Plan says the patient does not meet criteria for this 
procedure because the records show the patient does not have moderate to severe mitral regurgitation. Their 
regurgitation this month is documented as mild to moderate, and due to their dilated cardiomyopathy.  
The Plan follows Medicare rules. Medicare rules say that TEER is only covered for patients with symptomatic, 
moderate-to-severe or severe functional mitral regurgitation. 
 
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 TEER. Our reviewer says that TEER is 
not medically necessary in accordance with Medicare rules. Our physician reviewer found transcatheter mitral 
valve repair (TMVR) using TEER for a patient with only "mild-moderate mitral regurgitation" per cardiac 
catheterization in June 2023 is not appropriate. The documentation is inadequate to confirm fulfillment of 
published CMS guidelines for TMVR/TEER.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TEER have not been met. Therefore, we decided that the Plan does not have to 
pre-approve transcatheter edge-to-edge repair (TEER).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93313 billed for date of service February 7, 
2023. 
 You asked the Plan to pay for procedure code 93313. You say that this service is supported in the medical 
records. The Plan denied your request. The Plan says payment for code 93313 is bundled into payment for code 
00567. 
 
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 93313 
is a column II code to column I code 00567. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 93313 billed for date of service February 7, 
2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-one. 
 
You asked the Plan to pre-approve the injection. You say that the enrollee has health issues that do not make 
them a good candidate for a shoulder replacement. The Plan denied your request. The Plan says the enrollee 
does not have an FDA approved indication for the requested medication. 
 
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 the injection. Our reviewer says that the 
requested use of Gel-one is not supported. Our physician reviewer found that the record indicates that the 
enrollee has a diagnosis of arthritis of the shoulder. The FDA has not stated that the requested treatment is 
indicated for the enrollee's condition. The Medicare approved drug compendia do not contain a supportive 
citation for the use of the requested treatment in the enrollee's clinical situation.  
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gel-one.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that it is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary.  
 
Our physician reviewer found the enrollee is a 60-year-old with a diagnosis of diabetes with chronic kidney 
disease. A home health nurse to perform venipuncture for laboratory testing has been requested. At issue in this 
case is whether the home health nurse to perform venipuncture for laboratory testing is eligible for coverage 
under Medicare guidelines. The health plan denied coverage for the home health nurse to perform venipuncture 
for laboratory testing stating that the available medical records do not support necessity of the service as 
defined by Medicare criteria. The denial is being appealed.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the hyperbaric oxygen therapy visits 
provided from November 3, 2022, to November 22, 2022. 
 
You asked the Plan to waive the coinsurance for the oxygen therapy visits. You say that you had met your 
maximum out-of-pocket amount. 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 20% 
coinsurance for out-of-network outpatient diagnostic tests.  
 
You have been asked to pay $21.41, which is 20% coinsurance of the allowed amount for each oxygen therapy 
visit provided on November 3, 2022, November 4, 2022, November 7, 2022, November 8, 2022, November 10, 
2022, November 11, 2022, November 14, 2022, November 17, 2022, and November 22, 2022 ($107.06 
allowed amount x 20% = $21.41). You have also been asked to pay up to 20% coinsurance of the allowed 
amount for the oxygen therapy visit provided on November 18, 2022. You have been asked to pay $15.66. 
These items/services fall within the outpatient diagnostic tests and therapeutic services and supplies 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 coinsurance for the hyperbaric oxygen therapy visits provided 
from November 3, 2022, to November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 13, 2022. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the claim 
was beyond 12 months of the date of service and denied for timely filing submission. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the physician's services was not filed until February 6, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on January 13, 2022.