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

 
We decided that the Plan does not have to pre-approve Vraylar 3 milligram capsule. 
 
You asked the Plan to pre-approve the medication. You say that the requested medication is medically 
necessary for the enrollee's treatment for Bipolar II disorder. 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 Vraylar 3 milligram 
capsule.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99070 billed for date of service October 9, 
2023. 
 
You asked the Plan to pay for procedure code 99070. You say that the claim should be paid. The Plan denied 
your request. The Plan says procedure code 99070 is considered bundled and not separately payable.  
 
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 99070 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99070 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99070 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99070 billed for date of service October 9, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient services provided from April 12, 2023 
 
You asked the Plan to pay for the inpatient services. You say that the patient has chosen not to file a claim at 
this time. You also say that you are requesting review and reconsideration of this claim for conditional payment 
based on the Centers for Medicare & Medicaid Services (CMS) guidelines. The Plan denied your request. The 
Plan says that the claims have been denied until the claim has been filed and subsequently denied. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has not met its obligation with regards to coordination of benefits. Specifically, the record does not 
show that the Plan has sent the bill directly to the primary insurer for payment, directed the provider to send the 
bill to the primary insurer or paid for the services and submitted a bill for reimbursement to the primary insurer. 
Therefore, we decided that the Plan has to pay for the inpatient services provided from April 12, 2023  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GTC Hematology Profile billed with code 81455 for date 
of service June 2, 2023. 
 
You asked the Plan to pay for the GTC Hematology Profile. You say that this test was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this test was not billed with the 
appropriate CPT 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, the CPT Code Manual definition of code 81455 is targeted genomic sequence analysis panel, solid 
organ or hematolymphoid neoplasm or disorder, 51 or greater genes (e.g., ALK, BRAF, CDKN2A, CEBPA, 
DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, KRAS, MET, MLL, NOTCH1, NPM1, 
NRAS, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy number variants or rearrangements, or isoform expression or mRNA expression levels, if performed; DNA 
analysis or combined DNA and RNA analysis. 
 
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 GTC Hematology Profile. Our reviewer says that the 
CPT code reported is not appropriate for the test provided. Our reviewer found the CPT code reported cannot 
be verified in conjunction with the unique test identifier (DEX-Z code) billed. 
 
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 GTC Hematology Profile have not been met. Therefore, we decided that the 
Plan does not have to pay for the GTC Hematology Profile billed with code 81455 for date of service June 2, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided on July 29, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you would like the medical 
records to be reviewed for proof of delivery and the claim to be reprocessed and paid. The Plan denied your 
request. The Plan says the provider is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous 
glucose monitor (CGM) provided on July 29, 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 medical records provided support the need for 
care in an IRF. The Plan denied your request. The Plan says services can be provided in a lower level of care 
such as a skilled nursing facility (SNF).  
 
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. The patient was 
admitted for respiratory failure.  There are no complex nursing or rehabilitation needs.  The enrollee does 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 the enrollee 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the medical records provided support the 
need for care in an LTACH. The Plan denied your request. The Plan says services can be provided in the 
current hospital setting. 
 
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 a 66-year-old male who was admitted to the acute care hospital with 
hypothermia, hypoglycemia, fall, influenza pneumonia, acute on chronic congestive heart failure, and acute 
respiratory failure requiring oxygen support, BiPAP, vent support, diuresis, dobutamine, antibiotics, and paracentesis and complicated by sepsis, chronic wounds. Recent notes describe the enrollee as now afebrile 
without leukocytosis, tolerating low dose oxygen via nasal cannula, requiring simple wound care, and now off 
dobutamine drip. The enrollee appears to be improving with current treatment and should only require short-
term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer to a lower level of care. The enrollee does not require services at the LTACH that are 
not already available at the current facility.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99213) and paring or cutting of benign 
hyperkeratotic lesion (11057) provided on June 07, 2023. 
 
You asked the Plan to pay for an office visit (99213) and paring or cutting of benign hyperkeratotic lesion 
(11057). You say that you were unaware that the enrollees insurance had changed 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 (99213) and paring or cutting of benign hyperkeratotic lesion (11057) provided on June 
07, 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 an IRF admission to regain 
function and strength. The Plan denied your request. The Plan says the IRF services requested do not meet the 
requirements for approval.  
 
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 can be provided 
in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach 
to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical therapy and 
occupational therapy, but this can be provided in a lower level of care. There is documentation that there is a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF, but the services required can be provided 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the injection and the infusion services 
provided on September 25, 2023. 
 
You asked the Plan to waive the coinsurance for the injection and the infusion services. You say that you were 
told the injection was approved and were not informed of any coinsurance. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs.  
You have been asked to pay 20% coinsurance for the injection and the infusion services. This item/service falls 
within the Medicare Part B prescription 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. you have been asked to pay a total of $669.64, which is 20% of the allowed 
amount for these services. Therefore, we decided that the Plan does not have to waive the coinsurance for the 
injection and the infusion services provided on September 25, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled/residential facility services provided from 
February 1, 2023, through April 30, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the skilled/residential facility services. The Plan denied your request. The Plan 
says the physician is out of network and authorization was requested. 
 
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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 skilled/residential facility services provided from February 1, 2023, through April 30, 2023, by an out-of-
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220), 
intraoral - periapical additional radiographic image (D0230), and bitewings - four radiographic images (D0274) 
provided on August 21, 2023. 
 
You asked the Plan to pay for the dental services. You say that this provider is in-network with your plan. The 
Plan denied your request. The Plan says your benefit for the requested services $2,000 dollar limit was met. 
 
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 your benefit for dental services has been exhausted. The Plan has provided evidence of having made 
payments totaling $2,000 towards the cost of dental services provided in 2023. Therefore, we decided that the 
Plan does not have to pay for the intraoral - periapical first radiographic image (D0220), intraoral - periapical 
additional radiographic image (D0230), and bitewings - four radiographic images (D0274) provided on August 
21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that 
were issued on March 17, 2023. 
 
You asked the Plan to pay for the compression stockings. You say that you were not informed that the 
compression stockings would not be covered. You also say that had you know they were not covered you 
would never have bought them as they are expensive. The Plan denied your request.  The Plan says gradient compression stockings (A6530) are only covered when used as a primary or secondary dressing over wounds that meet the statutory requirements for a qualifying wound. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6530 that were issued on March 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 enrollee needs this care to return to daily 
activities and regain independence. The Plan denied your request. The Plan says medical records do not support 
the need for an IRF admission and, the enrollee needs can be provided at another setting.  
 
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 medical, rehabilitation, and nursing needs does not 
require IRF care with an interdisciplinary approach to rehabilitative care. The enrollee's rehabilitation needs 
can be safely provided in an alternate 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the seat lift mechanism, electric, any type (E0627) 
and sales tax (S9999) purchased on June 5, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to reimburse you for the seat lift mechanism. You say that you are appealing the denial for 
reimbursement of your medically needed medical lift assist recliner. The Plan denied your request. The Plan 
says enrollees must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 
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 reimburse you for care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and pre-approved care. 
 The Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item/service at issue. We found no exception that would 
require the Plan to reimburse you for these items/services. Therefore, we decided that the Plan does not have to 
reimburse you for the seat lift mechanism, electric, any type (E0627) and sales tax (S9999) purchased on June 
5, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided on August 11, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have submitted proof of 
delivery along with other supporting documentation, but the claim keeps denying for missing this information. 
You also say to please review the appeal letter and process the claim. The Plan denied your request. The Plan 
says the provider is not a plan contract provider and is not enrolled in Medicare as a durable medical equipment 
supplier. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous 
glucose monitor (CGM) provided on August 11, 2023.