Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve high dose rate electronic brachytherapy (0394T). 
 
You asked the Plan to pre-approve high dose rate electronic brachytherapy. You say that this service is 
medically necessary. The Plan denied your request. The Plan says this request cannot be approved is because 
there is not enough current research showing that the enrollee's type of cancer responds better to the requested 
type of treatment than the type of treatment the Plan can approve. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 high dose rate electronic brachytherapy. 
Our reviewer says that this request is not medically necessary. Our physician reviewer found the record 
indicates that the enrollee has basal cell carcinoma to the left nasal ala. There is insufficient literature to support 
the safety and efficacy, as defined by Medicare rules, of the requested service. Our reviewer also found that the 
record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of 
the requested service. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of high dose rate electronic brachytherapy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve high dose rate electronic brachytherapy (0394T).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the documentation fails to show that the enrollee continued to 
meet the conditions for SNF coverage. 
 
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 skilled nursing 
facility (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 skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Continuous Positive Air Pressure (CPAP) machine (E0601) 
provided on May 22, 2023. 
 
You asked the Plan to pay for the CPAP machine. You say that this item was medically necessary. The Plan 
denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 The record does not contain a valid proof of delivery for the supplies provided in this case. No proof of 
delivery was provided for the billed date of service. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for a Continuous Positive Air Pressure (CPAP) machine (E0601) provided on May 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services provided on 
May 09, 2023. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $245 
copayment for outpatient hospital services/Medicare-covered outpatient hospital services. 
 
You have been asked to pay a $245 copayment for outpatient hospital services. This item/service falls within 
the outpatient hospital services/Medicare-covered outpatient hospital services 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. However, since the allowed amount is 
less than the standard copayment, you only owe $118.42. Therefore, we decided that the Plan does not have to 
waive the copayment for outpatient hospital services provided on May 09, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 4, 2022. 
 
You asked the Plan to pay for the lab services. You say that the testing meets the requirements for coverage. 
The Plan denied your request. The Plan says an incorrect place of service was billed. 
 
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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on November 4, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services reported with procedure code A0999 
billed for date of service July 17, 2023. 
 
You asked the Plan to pay for procedure code A0999. You say that the services at issue were a necessity for 
your care. The Plan denied your request. The Plan says the billed code is a statutory exclusion.  
 
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 A0999 has a Status Indicator of X on the Physician Fee Schedule. This means that 
procedure code A0999 is a statutory exclusion. Based on this information, we decided that Medicare rules for coverage of procedure code A0999 have not been met. Therefore, we decided that the Plan does not have to 
pay for ambulance services reported with procedure code A0999 billed for date of service July 17, 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 IRF services are medically necessary. The Plan 
denied your request. The Plan says based on the available information, admission to an IRF is not reasonable 
and 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 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.  Our reviewer also found that 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that  admission is medically necessary for the enrollee.  
The Plan denied your request. The Plan says the enrollee was discharged to home, per therapy notes, physical 
therapy has "signed off" due to resistance to therapy and inability to follow commands. 
 
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 skilled nursing 
facility (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 skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple 
power options (K0861) and additional items and accessories (codes E0955, E1007, E1012, E1028, E2311, 
E2313, E2361, E2377, E2607, E2620, and K0108). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair with multiple power options and 
additional items and accessories. You say that your other wheelchair was stolen, and you need this wheelchair 
to get around because you are unable to walk. The Plan denied your request. The Plan says you do not have 
medical need for multiple power options included with K0861 group 3 power wheelchair. The Plan also says 
the electronic connection, expandable controller and expandable controller harness cannot be covered as it is 
not medically necessary to control the three requested power options through the joystick (drive interface). 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with multiple 
power options (such as code K0861) is covered if the criteria listed in the Medicare rules section of this letter 
are met. Medicare rules also say that if the PWC base is not covered, then related accessories will be denied. 
 
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 standard power wheelchair 
with multiple power options and additional items and accessories. Our reviewer says that the criteria for 
coverage have not been met. Our physician reviewer found you have multiple sclerosis (MS) and urinary 
incontinence. Per two notes on different dates by different providers, you are ambulatory with a walker. Our 
physician reviewer also found that you do not have high risk for skin breakdown, use a catheter intermittently, 
have spasticity or require an alternative means of managing power drive. 
 
 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 standard power wheelchair with multiple power options and 
additional items and accessories have not been met. Therefore, we decided that the Plan does not have to pre-
approve a group 3 standard power wheelchair with multiple power options (K0861) and additional items and 
accessories (codes E0955, E1007, E1012, E1028, E2311, E2313, E2361, E2377, E2607, E2620, and K0108).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea (J0178). 
 You asked the Plan to pre-approve Eylea. You say that you are requesting Eylea due to an Avastin shortage. 
The Plan denied your request. The Plan says the patient does not meet the criteria for coverage. 
 
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. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the provided records do not indicate that 
the patient has tried and failed the Plan's preferred step one alternative. Our reviewer found that the record does 
not indicate that the patient has 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 have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea (J0178).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eye screening services billed with code 92251 for date of 
service May 15, 2023. 
 
You asked the Plan to pay for eye screening services billed with code 92251. You say that you paid for these 
medically necessary out-of-network services up front, and you would like to be reimbursed the Plan's allowed 
cost for these services. The Plan denied your request. The Plan says this service was billed with a code which is 
not recognized by Medicare. No reimbursement amount can be verified with this 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. In this case, there is no CPT Code Manual 
definition of code 92251, as this is not a valid code and is not recognized by Medicare. 
 
We find that CPT code 92251 is not supported in the medical record. Specifically, this is not a valid code, and 
therefore no clear definition of the service provided or payable amount for the service can be verified. Based on 
this information, we decided that Medicare rules for coverage of eye screening services have not been met. You 
may wish to contact the out-of-network provider to clarify the service provided and get a new CPT code. Therefore, we decided that the Plan does not have to pay for eye screening services billed with code 92251 for 
date of service May 15, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from December 4, 2022, to 
December 30, 2022. 
 You asked the Plan to pay for the home health services. You say that this claim was been denied incorrectly. 
The Plan denied your request. The Plan says the valid NOA was not received. 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 NOA was not received by the Plan. As a result, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for home health services provided from December 4, 
2022, to December 30, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0299, Q5001) provided on March 
17, 2023 to April 13, 2023. 
 
You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
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 find that CPT codes G0299, & Q5001 are not supported in the medical record. Specifically, the claim was 
billed with a frequency code of "8" which is used to void the claim. Based on this information, we decided that 
Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for home health services (G0299, Q5001) provided on March 17, 2023 to April 13, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the myocardial perfusion imaging, and the 
technetium tc-99m sestamibi injection provided by an in-network provider on April 21, 2023. 
 
You asked the Plan to waive the cost sharing for the imaging and the injection. You say that you were told that 
you would only be responsible for a copayment. 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. Your 
contract with the Plan says that there is a $471 in and out-of-network deductible which applies to medical 
supplies, and that you must pay a $15 copayment for in and out-of-network Medicare-covered radiological 
diagnostic services at a specialist office.   
 You have been asked to pay a $15 copayment for the imaging. You have also been asked to pay a $272 
deductible for the injection. The items or services you asked the Plan to waive the cost sharing for fall within 
the outpatient diagnostic tests and therapeutic services and supplies benefit category. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $471 in and out-of-network deductible which 
applies to outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual 
obligation that had not been met at the time the injection was received on April 21, 2023. Therefore, we 
decided that the Plan does not have to waive the cost sharing for the myocardial perfusion imaging, and the 
technetium tc-99m sestamibi injection provided by an in-network provider on April 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on June 13, 2023, billed with 
codes 87481, 87491, 87563, 87640, 87653, 87798, 87641 and 87500. 
 
You asked the Plan to pay for the laboratory testing billed. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on 
the claim. 
 
The Plan must follow Medicare rules. The rules say that if a laboratory procedure produces multiple reportable 
test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. This was a panel test that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the laboratory testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing 
provided on June 13, 2023, billed with codes 87481, 87491, 87563, 87640, 87653, 87798, 87641 and 87500.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on June 05, 
2023. 
 
You asked the Plan to pay for an office visit and related services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit and 
related services provided on June 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the inpatient hospital stay provided on 
February 03, 2023, to February 09, 2023. 
 
You asked the Plan to reduce the copayment for the inpatient hospital stay. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for inpatient hospital care. 
 
You have been asked to pay a $275 copayment for the inpatient hospital stay. This item/service falls within the inpatient hospital care 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. You have been asked to pay a total of $1,375 for the inpatient hospital stay ($275 
copayment x 5 days = $1,375). You have not been charged for the day you were discharged. Therefore, we 
decided that the Plan does not have to reduce the copayment for the inpatient hospital stay provided on 
February 03, 2023, to February 09, 2023.