Persius/hicric huggingface dataset:
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 enrollee has had multiple hospital 
admissions for COPD along with respiratory failure. The enrollee is needing a ventilator to help with chronic 
respiratory failure. The Plan denied your request. The Plan says the enrollee does not meet criteria for approval 
of a ventilator. 
 
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 and 
obstructive sleep apnea. The enrollee was recently hospitalized, and an arterial blood gas (ABG) was consistent 
with acute on chronic hypercarbic respiratory failure. There is no diagnosis of thoracic restrictive disease or 
neuromuscular disease. There are no pulmonary function tests to assess the severity of the COPD. There is no 
ABG done while stable to document chronic carbon dioxide (CO2) retention.  If that is present, the enrollee 
may benefit from bilevel positive airway pressure (BiPAP) with average volume-assured pressure support 
(AVAPS) during sleep. Medicare does not cover a home ventilator when used at settings that can be provided 
with BiPAP. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the drug, Injection, pembrolizumab, 1 mg (J9271). 
 
You asked the Plan to pre-approve the drug, Injection, pembrolizumab. You say that the enrollee's weight is 
100 pounds and will not be able to handle chemotherapy. The Plan denied your request. The Plan says 
Medicare references do not support the use of the requested drug as a single agent in the first- line setting for 
adenocarcinoma subtype. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 drug, Injection, pembrolizumab. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the drug, Injection, 
pembrolizumab is not supported and not recommended.  
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 drug, Injection, pembrolizumab have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the drug, Injection, pembrolizumab, 1 mg (J9271).
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. The Plan denied your request. The Plan says the enrollee does not 
meet all the requirements for inpatient rehabilitation. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: 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. The Plan denied your request. The Plan says the enrollee's 
condition does not meet the requirements. Services needed may be provided safely in a lower level of care. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the presbyopia correcting function of intraocular lens (P-C 
IOL) (V2788), extracapsular cataract removal with insertion of intraocular lens (IOL) prosthesis (66984), 
Adrenalin epinephrine injection (J0171), midazolam hydrochloride (J2250), electrocardiogram (ECG) (93005), 
and additional services provided on January 4, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the P-C IOL, extracapsular cataract removal with insertion of IOL prosthesis, 
Adrenalin epinephrine injection, midazolam hydrochloride, ECG, and additional services. You say that 
medically necessary services were provided, and you fulfilled your obligations as a healthcare provider. You 
also say that it is your expectation that this claim will be reprocessed so you can be reimbursed for the services 
that were provided to the enrollee, in good faith. The Plan denied your request. The Plan says this request was 
denied because the service was rendered by an OON provider, and was available within the Plan's network. 
 
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. Medicare rules also say that if an enrollee receives a P-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C IOL and a 
conventional IOL. 
 
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. While 
a P-C IOL may be appropriate for the enrollee, neither the Plan nor Medicare covers the presbyopia-correcting 
feature of a P-C IOL. Therefore, we decided that the Plan does not have to pay for the presbyopia correcting 
function of intraocular lens (P-C IOL) (V2788), extracapsular cataract removal with insertion of intraocular 
lens (IOL) prosthesis (66984), Adrenalin epinephrine injection (J0171), midazolam hydrochloride (J2250), 
electrocardiogram (ECG) (93005), and additional services provided on January 4, 2022, by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 1, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided on May 1, 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 the enrollee requires close medical oversight 
regarding the complex medical issues. The Plan denied your request. The Plan says the enrollee's medical 
conditions have stabilized, and the records do not show the need for intensive services consisting of 3 hours of 
daily therapies for rehabilitation. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for atezolizumab provided on November 9, 2021. 
 
You asked the Plan to pay for the drug. You say that  The Plan denied your request. The Plan says that 
atezolizumab is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 pay for the drug. Our reviewer says that 
atezolizumab is not medically necessary. Our physician reviewer found that atezolizumab is FDA-approved. 
Although atezolizumab is not supported by one of the major drug compendia or by clinical research, it is safe 
and effective and otherwise reasonable and necessary for the enrollee. 
 
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 drug have been met. Therefore, we decided that the Plan has to pay for 
atezolizumab provided on November 9, 2021.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have pre-approval for additional transportation mileage. 
 
  You asked the Plan pre-approval for additional mileage. You say that you feel comfortable with the provider 
you have requested to be transported to, and this is medically necessary. You also say that you get better care 
with this cardiologist than with you do with any other cardiologist. The Plan denied your request. The Plan says 
the mileage from your home to the providers office is 56.2 miles (with highways) and 57.8 miles (without 
highways, with and without tolls) which is 6.2 to 7.8 miles over your allowed benefit per one-way trip. 
 
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 routine transportation when each one-way trip must not exceed 50 miles of driving 
distance. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the location you 
have requested to be transported to is over the allowed limit of 50 miles of driving distance. Therefore, we 
decided that the Plan does not have pre-approval for additional transportation mileage.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services billed for dates of service 
December 25, 2022, and December 30, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says your coverage 
does not provide for this service. The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept services billed for dates of service December 25, 2022, and December 30, 2022.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure codes 83036 and 80048. We 
decided that the Plan does not have to pay for the services described by procedure code 82310.  
 
You asked the Plan to pay for procedure codes 83036, 82310, and 80048 billed for date of service March 7, 
2023.. You say that you disagree with the Plan's denial. The Plan says that the services billed are not payable. 
 
We decided that the Plan has to pay for the services described by procedure codes 83036 and 80048.  
 
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. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure codes 83036 and 80048.  
 
We also decided that the Plan does not have to pay for the services described by procedure code 82310. 
 
The Plan follows 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 82310 is a 
column II code to column I code 80048. This claim has not been billed with an appropriate modifier to bypass 
the edit. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services described by procedure code 82310 have not been met. Therefore, we decided that the 
Plan does not have to pay for the services described by procedure code 82310. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs more intensive rehabilitation to 
return to prior level of function. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary.  
 
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 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. 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for pontic - porcelain/ceramic (D6245) x2 provided on 
April 6, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you should not have to pay the billed 
amount because the predetermination document you received showed no enrollee responsibility. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid $84 on date of service February 7, 2023, $318 on date of service February 24, 2023, $314 
on date of service March 7, 2023, and $2,284 on date of service April 6, 2023 ($84 + $318 + $314 + $2,284 = 
$3,000). After the annual maximum is exhausted, any remaining charges are your responsibility. Therefore, this 
benefit has been exhausted as of July 6, 2023. Therefore, we decided that the Plan does not have to pay more 
for pontic - porcelain/ceramic (D6245) x2 provided on April 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 80307 billed for date of service December 
15, 2022. 
 
You asked the Plan to pay for the billed services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says there is no documentation supporting the testing. 
 
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 80307 is presumptive drug testing for any number of 
drug classes. We find that CPT code 80307 is not supported in the medical record. The records state that the 
enrollee will have urine drug testing performed. However, the records do not show that this lab testing was 
provided on the date of service at issue.  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 80307 billed for date of 
service December 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. You say that you need the second injection for you to function 
because you cannot hold a phone. The Plan denied your request. The Plan says an epidural steroid injection 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 injection. Our reviewer says that 
you do not meet the coverage criteria. Our physician reviewer found that there is no documentation of a least 
50% sustained improvement in pain relief or improvement in function measured from baseline using SAME 
scale for at least three months. Therefore, you do not meet the LCD coverage criteria. 
 
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 an epidural steroid injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Cimerli injection provided on April 21, 
2023. 
 
You asked the Plan to waive the coinsurance for a Cimerli injection. You say that you are appealing with 
supporting records. 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 Medicare Part B drugs.  
 
 
  You have been asked to pay $273 coinsurance, which is 20% of the allowed amount for a Cimerli injection 
($1,365 x 20% = $273). This item/service falls within the Medicare Part B drugs 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 a Cimerli injection provided on April 21, 2023.