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

 
We decided that the Plan does not have to pay for the pneumatic compression device and appliance provided 
on March 10, 2023. 
 
You asked the Plan to pay for the pneumatic compression device and appliance. The Plan denied your request. 
The Plan says this is not covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device and appliance provided on March 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to a tertiary-level gastroenterologist. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the tertiary level of care is not reasonable or 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 these services. Our reviewer says that 
the tertiary level of care is not reasonable or medically necessary. Our physician reviewer found the records 
show that you have a history of colon cancer that requires a colonoscopy every two years. The submitted 
records do not support that your condition requires the tertiary level of care for a second opinion or 
colonoscopy. Tertiary care is not the standard of care and your needs can be properly met with the Plan's non-
tertiary gastroenterologist.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a referral to a tertiary-level gastroenterologist.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested  
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. You say that the providers at the requested facility know what they are doing and you do not feel the 
Plan is acting in your best interest. The Plan denied your request. The Plan says you are in a closed HMO Plan 
with no out-of-network benefits. The medical records were reviewed and there is no mention of your current 
neurologist seeking another professionals opinion elsewhere. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.
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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet all the requirements for an IRF admission. 
 
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 you do 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 or occupational therapy, there is no documented need for intensive rehabilitation 
services. There is not a reasonable expectation that you 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 14, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have billed the services at issue correctly. 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 lab services provided on December 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron tablets. 
 
You asked the Plan to pre-approve Ondansetron tablets. You say that this medication will be available for use 
outside of the immediate period before chemotherapy. 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 Ondansetron tablets.  
 
Benefits for Ondansetron tablets 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 seat lift mechanism. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
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 these services. Our reviewer says that 
the criteria for coverage are not met. Our physician reviewer found the records show that you have a history of Type II diabetes, a stroke with resulting left-sided weakness, high blood pressure, and rapid heartbeat (atrial 
fibrillation). The physical therapy assessment dated May 31, 2023 indicates you have three to four out of five 
motor strength in your arms and can walk with a rolling walker and assistance. You are able to perform 
transfers independently. The criteria for coverage of the seat lift mechanism are not met and the services are 
therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a seat lift mechanism.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81406 for date of service January 10, 2023.  
 
You asked the Plan to pay for procedure code 81406. You say that you disagree with the Plan's denial. 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 procedure code 81406 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 81406 for date 
of service January 10, 2023.
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 October 27, 
2022, to November 25, 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 October 27, 2022. The NOA was not received by the Plan until November 
26, 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 the home health services for 
date of service October 27, 2022, to November 25, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat transthoracic echocardiography (TTE) (93306). 
 
You asked the Plan to pre-approve a repeat TTE. The Plan denied your request. The Plan says the records do 
not show that the enrollee has heart disease that is related to high blood pressure. 
 
The Plan follows Medicare rules. Medicare rules say that absent acute intervention, or a discrete change in 
otherwise stable clinical signs and symptoms, it is not medically necessary to repeat TTE examinations more 
frequently than annually. 
 
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 repeat TTE. Our reviewer says that a 
repeat TTE is not medically reasonable and necessary. Our physician reviewer found the documentation at this 
time would not point to a change in status that would support the medical necessity of a repeat TTE. Clinical 
guidelines do not support repeating a TTE with no intervening change in clinical status or new signs, 
symptoms, or physical findings. Our reviewer also found that in summary, there is no supportive evidence for 
the medical necessity of repeat TTE in this this enrollee's clinical management. 
 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 repeat TTE have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat transthoracic echocardiography (TTE) (93306).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve contour test Invitro strips. 
 
You asked the Plan to pre-approve contour test strips. You say that you have type 2 diabetes and have been 
using the requested product since May 1, 2020. You need to continue with this product. The Plan denied your 
request. The Plan says only the preferred brand products listed in the EOC are covered.  
 
 The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for contour test strips. Specifically, the documentation submitted does not include any clinical information to 
verify that you have tried and failed the Plan's preferred brands or that the Plan's preferred brands would be 
contraindicated for you. The file does not include any documentation from your physician documenting why 
you require this specific brand of test strips. Without this, medical necessity cannot be established. Therefore, 
we decided that the Plan does not have to pre-approve contour test Invitro strips.
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 needs the next level of care 
and cannot move to a skilled nursing facility. The Plan denied your request. The Plan says criteria for 
admission to the LTACH have not been met.  
 
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 is receiving an appropriate level of care in the present setting. The 
acute hospital can provide for all the enrollee's present inpatient care needs, and the Plan has not stated that 
continued care in the short-term acute hospital will not be covered. Continued care in the short-term acute 
hospital is appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient 
rehabilitation facility, a sub-acute rehabilitation facility or a skilled nursing 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.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services and mileage billed with codes A0428 
and A0425 for date of service March 15, 2023. 
 
You asked the Plan to pay for the ambulance services and mileage. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. 
 
We looked at the file and Medicare rules. Review of the file shows that these services were billed with 
diagnosis codes R52 and M25.559. Due to an Excludes1 note, these two diagnosis codes should not be billed 
together. This means these codes are not payable as billed. Based on this information, we decided that 
Medicare rules for coverage of the ambulance services and mileage have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services and mileage billed with codes A0428 and A0425 
for date of service March 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0426 billed for date of service April 23, 
2023. You asked the Plan to pay for the billed services. You say that the charge session is correct per the 
documentation. The Plan denied your request. The Plan says the rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code G0426 was billed with place of service code 23. Based on this information, we decided 
that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code G0426 billed for date of service April 23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the hip surgery provided on January 25, 
2023, to January 26, 2023. 
 
You asked the Plan to waive the coinsurance for the hip surgery. You say that you cannot afford this 
coinsurance. 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 40% 
coinsurance for out-of-network outpatient surgery. 
 
You have been asked to pay 40% coinsurance for the hip surgery. This item/service falls within the out-of-
network outpatient surgery 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. The total you owe is $4,788.64 ($11,971.61 allowed amount x 40% coinsurance = 
$4,788.64). Therefore, we decided that the Plan does not have to waive the coinsurance for the hip surgery 
provided on January 25, 2023, to January 26, 2023.
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 the enrollee would benefit from physical therapy 
and occupational therapy. You also say SNF services are necessary for the enrollee to regain strength. The Plan 
denied your request. The Plan says the enrollee does not meet the requirement for admission to a SNF.  
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten (10) additional physical therapy visits.  
 
You asked the Plan to pre-approve ten (10) additional physical therapy visits. You say that ten (10) additional 
physical therapy visits are medically necessary. The Plan denied your request. The Plan says ten (10) additional 
physical therapy visits are not medically necessary.  
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 ten (10) additional physical therapy 
visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found that the enrollee has a medical history of 
pulmonary fibrosis requiring supplemental oxygen and weakness. Physical therapy documentation dated  
May 15, 2023 indicated that the enrollee has been receiving in home health physical therapy since 
November 22, 2022. The enrollee is noted to have 4-5/5 motor strength in the upper and lower extremities. The 
enrollees oxygen saturation is noted to drop with activity, especially when negotiating stairs. The enrollee is 
noted to have fair to good balance and safety awareness. The requested physical therapy is generally accepted 
as a specific and effective therapy for decreased endurance due to respiratory failure. At this point the enrollee 
has nearly full motor strength in the upper and lower extremities and her function is primarily limited by her 
pulmonary function. The enrollee can ambulate with a walker and perform transfers independently. The 
enrollee must take frequent breaks to avoid being short of breath. The enrollees level of function and progress 
with therapy has plateaued and she has been educated in terms of safely ambulating and taking rest breaks. The 
enrollee has been educated in terms of a home exercise program in terms of maintaining her level of endurance. 
Therefore, the 10 visits of additional physical therapy are 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 ten (10) additional physical therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve ten (10) additional physical therapy visits.