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

 
We decided that the Plan does not have to pay for the TDAP (tetanus, diphtheria, and pertussis) vaccine you 
received on June 30, 2023. 
 
You asked the Plan to pay for the TDAP vaccine. You say that you are surprised by this bill. The Plan denied 
your request. The Plan says the TDAP vaccine is not covered under your medical benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the TDAP vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the TDAP vaccine. 
In addition, your medical records show that your doctor advised you that this vaccine would likely not be 
covered.  You told your doctor that due to your diagnosis, it should be covered, and you decided to proceed 
with the vaccine anyway. Therefore, we decided that the Plan does not have to pay for the TDAP (tetanus, 
diphtheria, and pertussis) vaccine you received on June 30, 2023.  
 Benefits for the TDAP vaccine 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets criteria for an LTACH 
level of care and would benefit from receiving continued acute care services at an LTACH. You also say the 
enrollee will require a minimum of 25 days of long-term acute care, and that lower levels of care are not an 
option and would place the enrollee at a high risk for readmission. The Plan denied your request. The Plan says 
the records do not show that is it medically necessary for the enrollee to be in an LTACH in place of an acute 
care hospital.  
 
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 has peripheral artery disease, diabetes (type 2), bilateral below-knee 
amputations, and congestive heart failure. The enrollee was admitted over 1 month ago with hypoxic 
respiratory failure requiring intubation because of sepsis from an amputation stump osteomyelitis. The enrollee 
had a tracheostomy and percutaneous endoscopic gastrostomy (PEG) placed. The enrollee is being treated for 
multiple infections, including C. difficile. The enrollee has been agitated, pulling at their ventilator and lines. 
The enrollee has a right lower lobe pneumonia and is currently on T-piece most of the day and ventilator 
support at night. The enrollees needs are being met in the current setting and there is no therapeutic benefit to 
transfer to LTACH. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve and home delivered prepared meals (S5170). 
 
You asked the Plan to pre-approve home delivered prepared meals (S5170). You say that you are on a fixed 
income and cannot afford healthy food. The Plan denied your request. The Plan says the request does not meet 
criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that meals may be offered as a supplemental benefit 
immediately following surgery or an inpatient hospital stay, or for a chronic condition, for a temporary period.  
 
We looked at the file and Medicare rules. The record shows that meals delivered to your home are excluded 
from this benefit. Based on this information, we decided that Medicare rules for coverage of home delivered 
prepared meals (S5170) have not been met. Therefore, we decided that the Plan does not have to pre-approve 
and home delivered prepared meals (S5170).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methylprednisolone 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has pain, limited range of motion, 
and numbness of the hip. 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 Methylprednisolone  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Purewick external female catheter system, a non-
covered item or service (A9270). 
 
You asked the Plan to pre-approve a Purewick catheter system. You say that the Purewick system will greatly 
improve your quality of sleep and life functioning during the day. The Plan denied your request. The Plan says 
the requested system is a non-covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Purewick catheter system have not been met. Specifically, the Purewick system is not a covered 
benefit with Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve a Purewick 
external female catheter system, a non-covered item or service (A9270).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from June 9, 2023, to June 10, 
2023. 
 You asked the Plan to pay for the home health services. You say that you have provided medical records to 
support payment. 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 June 9, 2023. The NOA was not received by the Plan until August 25, 
2023. 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 home health services provided 
from June 9, 2023, to June 10, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve imatinib mesylate. 
 
You asked the Plan to pre-approve the medication. 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 imatinib mesylate.  Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (G0463) provided on May 30, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
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 payment for CPT code G0463 is not supported in the medical record. Specifically, this code was 
billed with modifier GY, which means that this service is either statutorily excluded or does not meet the 
definition of any Medicare benefit. You were informed that these services would not be covered. Based on this 
information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we 
decided that the Plan does not have to pay for the services (G0463) provided on May 30, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Zilretta. 
 
You asked the Plan to pre-approve Zilretta. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
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 Zilretta. Our reviewer says that the 
services are medically necessary. Our physician reviewer found the Food and Drug Administration has stated 
that the requested drug is indicated as an intraarticular injection for treatment of osteoarthritis-related knee 
pain. The current Food and Drug Administration label does not prohibit repeat administration. The record 
provided indicates that the enrollee has had efficacious results with treatment using the requested drug and 
establishes the medical necessity and reasonableness, as defined by Medicare rules, of the requested 
service. The elements of the coverage criteria are satisfied. The requested service is 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 Zilretta have been met. Therefore, we decided that the Plan has to pre-approve 
Zilretta.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prefabricated abutments - includes modification and 
placement  (D6056), surgical placement of implant body: endosteal implants (D6010), interim complete 
denture (maxillary) (D5810), and interim complete denture (mandibular) (D5811) provided on July 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that these dental services are medically necessary. 
The Plan denied your request. The Plan says these services are not covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
prefabricated abutments - includes modification and placement  (D6056), surgical placement of implant body: 
endosteal implants (D6010), interim complete denture (maxillary) (D5810), and interim complete denture 
(mandibular) (D5811) provided on July 12, 2023.
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 admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee's records do not show to have a condition 
which requires continued inpatient hospital care with daily rehabilitation visits for more than 25 days. 
 
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 appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate at this time. 
 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total knee replacement (27444). 
 
You asked the Plan to pre-approve a total knee replacement. You say that this is medically necessary. The Plan 
denied your request. The Plan says this 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 a total knee replacement. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation regarding a trial and failure of recent, reasonable, 
comprehensive, less invasive conservative care measures is not evident. Formal physical therapy is not clearly 
documented to have been recently trialed and failed. There is not any indication of injection therapy having 
failed. Conservative care measures are typically needed to have failed prior to moving forward with surgical 
intervention. Moreover, the provided radiologist report of the radiographs of the right knee did not appear to 
corroborate end-stage osteoarthritis as the treating provider had noted. There are limited large-scale, long-term 
references showing the safety and efficacy of the requested surgery in this clinical setting. There is no 
compelling rationale presented, or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
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 total knee replacement have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total knee replacement (27444).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Deplin. 
 
You asked the Plan to pre-approve Deplin. You say that Deplin is medically necessary. The Plan denied your 
request. The Plan says this item is considered a nutritional supplement and is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve Deplin.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital inpatient or observation care visits 
(procedure 99232) provided from February 23, 2023, to April 18, 2023. 
 
You asked the Plan to pay for subsequent hospital inpatient or observation care visits (procedure 99232). You 
say that procedure code 99232 is appropriate based on the level of services required. The Plan denied your 
request. The Plan says procedure code 99232 is not supported by the documentation submitted. 
 
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 99232 is subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and moderate level of medical decision making. When using total time on the date of the 
encounter for code selection, 35 minutes must be met or exceeded. 
 
 
  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 subsequent hospital inpatient or observation care visits 
(procedure 99232). Our reviewer says that the records do not support the services at issue in this case. Our 
reviewer found that the enrollee has type 2 diabetes and chronic kidney disease and is in the intensive care unit 
(ICU) with decompensated asthma and myocardial injury. The provided documentation from the 
endocrinologist fails to support moderate decision-making. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of subsequent hospital inpatient or observation care visits (procedure 99232) have 
not been met. Therefore, we decided that the Plan does not have to pay for subsequent hospital inpatient or 
observation care visits (procedure 99232) provided from February 23, 2023, to April 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for thelab services provided on May 9, 2023. 
 
You asked the Plan to pay for the lab services. 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 thelab services provided on May 9, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the Ez Tears eye vitamin purchased on March 11, 
2023. 
 
You asked the Plan to reimburse you for the Ez Tears. You say that you attempted to use your benefit card but 
it was not accepted. You say that you were not aware that this card could not be used online. You also say that 
you should be reimbursed for this. The Plan denied your request. The Plan says you did not use the benefit card 
for payment. The Plan also says that other forms of payment are not eligible for reimbursement. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and Ez Tears is 
an OTC item. Additionally, the Evidence of Coverage clearly states that any other forms of payment are not 
eligible for reimbursement. Therefore, we decided that the Plan does not have to reimburse you for the Ez 
Tears eye vitamin purchased on March 11, 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 rehabilitation is both physically and medically 
necessary. The Plan denied your request. The Plan says the records do not show that the enrollee's 
rehabilitation needs are complex and need to be seen 3 times per week for 
evaluation of functional and medical goals and progress.  
 
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 enrollees nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement however, the documentation 
doesnt support that she would meet criteria for admission to an acute inpatient rehabilitation facility.  There is 
no indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation 
services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or 
maintain functional status.  The enrollee can receive further services 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.