Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chronic care management services and the remote 
physiologic monitoring provided on June 30, 2023, by an OON provider.  
 
You asked the Plan to pay for the chronic care management services and the remote physiologic monitoring. 
You say that you say that the service was medically necessary. The Plan denied your request. The Plan says the 
service was 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 chronic care management services and the 
remote physiologic monitoring provided on June 30, 2023, by an OON provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service July 16, 
2023 to August 12, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
were authorized. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service July 16, 2023 to August 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with single power option 
(tilt, legrests) and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with single power option. You say that the 
enrollee has had a change in their condition as they were hospitalized in July 2023. You say that the enrollee's 
ability to safely transfer out of their wheelchair has been limited. You also say that the enrollee has begun to 
plateau in their progress with therapy. The Plan denied your request. The Plan says the records show that a 
push wheelchair was approved in 2022, less than 5 years ago. The Plan also says that the request for a 
replacement power wheelchair cannot be covered. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with single power option 
may be covered when certain criteria 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 a Group 3 power wheelchair with single 
power option. Our reviewer says that the requested Group 3 power wheelchair with single power option is not 
medically necessary. Our physician reviewer found the medical records provided do not document that the 
Group 3 power wheelchair with single power option (tilt, leg rests) and accessories at issue meets all Medicare 
criteria for medically reasonable and necessary for the patient. The reviewer found that the provided records in 
this case do not document that the patient's present manual tilt-in-space wheelchair (E1161 approved in August 
2022) does not meet their mobility needs. Therefore, the reviewer found that the requested Group 3 power 
wheelchair 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 a Group 3 power wheelchair with single power option have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with single 
power option (tilt, legrests) and accessories.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF services from April 23, 2023, to May 22, 2023. 
 You asked the Plan to pay for SNF care. You say that the services which the enrollee required and received 
during the period in question are coverable. The Plan denied your request. The Plan says the enrollee's 
condition no longer required daily skilled services at a SNF level of care. 
 
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 pay for 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 did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did 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 pay for SNF services from April 23, 2023, to May 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on July 31, 2023, billed with 
procedure code 99213-25. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that in this case, medical record does not 
include documentation of a significant, separately identifiable evaluation and management service.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on July 31, 2023, billed with procedure code 
99213-25.
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 services you need can be provided safely in other settings, for example, 
a skilled nursing facility (SNF), at home with home health services or at home with outpatient therapy.  
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems 
are stable and there are no complex nursing or rehabilitation needs. 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 and/or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 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.  
 
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 pre-approve 4 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the additional PT visits will help your 
condition. The Plan denied your request. The Plan says you do not meet the criteria for the additional PT visits. 
 
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 the therapy services. 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 you have chronic stable back pain. The record does not indicate why 
additional therapy is necessary based on your response to previous therapy. The continued input from a skilled 
therapist is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 4 additional physical therapy (PT) visits.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea HD (J3590). 
 You asked the Plan to pre-approve Eylea HD. You say that the enrollee has had past treatment with Avastin, 
Vabysmo, and Eylea (J0178). The provider also says that the enrollee has already failed Eylea (J0178). The 
Plan denied your request. The Plan says based on comparable efficacy and safety profiles, for a diagnosis of 
Neovascular (Wet) Age-Related Macular Degeneration (nAMD), Diabetic Macular Edema (DME), or Diabetic 
Retinopathy (DR) use of Eylea HD will not be authorized unless there is adequate justification as to why Eylea 
cannot be used. The Plan also says that the use of Eylea HD due to convenience of administration will not be 
considered medically necessary and will not be authorized. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Eylea HD. Our reviewer says that the 
enrollee does not meet the criteria for Eylea HD (J3590). Our physician reviewer found the provided records do 
not indicate that the enrollee has tried and failed the plan's preferred step one alternative, have a 
contraindication to, or would have an adverse effect from the plan's preferred step one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea HD have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Eylea HD (J3590).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reblozyl. 
 
You asked the Plan to pre-approve Reblozyl. You say that the enrollee has problems with iron overload and the 
requested use of Reblozyl is medically necessary. The Plan denied your request. The Plan says the enrollee 
does not meet the requirements 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 Reblozyl. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the record indicates that the enrollee has a 
diagnosis of high-risk myelodysplastic syndrome. The Food and Drug Administration has not stated that the 
requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not contain 
a supportive citation for the use of the requested drug in the enrollee's clinical situation. The record provided is 
insufficient to establish that the enumerated requirements of the coverage article are satisfied. The record 
provided does not establish the medical necessity and reasonableness as defined by Medicare rules of the 
requested service. The elements of the coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Reblozyl have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Reblozyl.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management (E&M) services described 
by code 99214 and the Outpatient Intravenous Insulin Therapy (OIVIT) services described by codes 96365, 
96366, and 96521 performed on September 6, 2023. 
 
You asked the Plan to pay for the E&M and OIVIT services. You say that the E&M and OIVIT services should 
be paid as billed because they are supported in the record. The Plan denied your request. The Plan says the 
E&M and OIVIT services are denied because they are not supported in the record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules say also that OIVIT is not reasonable 
and necessary for any indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are 
nationally non-covered under Medicare when furnished pursuant to an OIVIT regimen. 
 
In this case, the CPT Code Manual definition of code 99214 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total 
time is spent on the date of the encounter. 
 
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 E&M services. Our reviewer says that the 
E&M services described by code 99214 are not supported in the documentation. Our reviewer found the 
enrollee is a 71-year-old who was seen for a follow-up and progressive infusion of insulin pump for diabetes. 
The enrollee was stable and tolerated the infusion without complication. Plans included continuing the same 
medications, diet, and follow-up. The documentation includes an appropriate history and examination; 
however, the documentation does not support a moderate level of medical decision-making or the duration of 
the encounter lasting 30-39 minutes. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of E&M and OIVIT services have not been met. Therefore, we decided that the 
Plan does not have to pay for the evaluation and management (E&M) services described by code 99214 and the 
Outpatient Intravenous Insulin Therapy (OIVIT) services described by codes 96365, 96366, and 96521 
performed on September 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the requested CGM is medically necessary. The 
Plan denied your request. The Plan says the Medicare coverage criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the CGM coverage criteria requires low 
blood sugars or insulin use. This enrollee is not having low blood sugars that we are told of. Although the 
enrollee takes Glipizide that can cause low blood sugars, we are not told of any symptomatic or troublesome 
low blood sugars. Although a CGM may help this enrollee, the coverage criteria for a CGM are not met. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance response without transport 
provided on July 8, 2023. 
 
You asked the Plan to waive the copayment for an ambulance response without transport. You say that you 
shouldn't be responsible for this charge because you did not call the ambulance. The Plan denied your request. 
The Plan says this processed correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport. However, the Plan offers an ambulance service benefit that exceeds Medicare coverage. 
For that reason, the Plans coverage rules apply in this case. The Plan contract states that enrollees must pay a 
$270 copayment for each non-Medicare covered ambulance stabilization when there is no transport. 
 The ambulance company did not provide transport services on July 8, 2023. You have been asked to pay $250 
for this non-Medicare covered ambulance stabilization because the allowed amount for this service is less than 
your listed $270 copayment. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an 
ambulance response without transport provided on July 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve group 3 power wheelchair with power tilt power option. 
 
You asked the Plan to pre-approve group 3 power wheelchair with power tilt power option. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the requested device is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair with power tilt is only 
covered for certain indications. 
 
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 group 3 power wheelchair with power 
tilt power option. Our reviewer says that the documentation does not support that the requested power 
wheelchair with power tilt is medically reasonable or necessary. Our physician reviewer found the enrollee has 
a past medical history including a stroke with hemiplegia and vascular dementia. The enrollee has a neurologic 
disorder with functional deficits. The documentation does not indicate that the enrollee has any pressure 
injuries or requires intermittent catheterization of the bladder or have spasticity that would necessitate power 
tilt or recline. Although the enrollee's condition may meet criteria for a power wheelchair, the criteria for this 
specifically requested power wheelchair are not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of group 3 power wheelchair with power tilt power option have not been met. 
Therefore, we decided that the Plan does not have to pre-approve group 3 power wheelchair with power tilt 
power option.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the record indicates that the enrollee has 
unspecified dementia, Alzheimer's disease, and multifactorial encephalopathy. The record provided does not 
establish that the enrollee meets the diagnostic criteria of both Alzheimer's disease and frontotemporal 
dementia or that the examination is being requested in the context of a clinical trial. The elements of the 
coverage criteria are not satisfied. 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.