Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 additional home health (HH) physical therapy (PT)
visits.
You asked the Plan to pre-approve 12 additional HH PT visits. You say that the 12 additional HH PT visits are
medically necessary. The Plan denied your request. The Plan says the 12 additional HH PT visits are not
medically necessary at this time.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically
necessary for the enrollee to receive skilled nursing or 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 12 additional HH PT visits. Our
reviewer says that the 12 additional HH PT visits are not medically necessary at this time. Our physician
reviewer found the enrollee's functional level does not require skilled therapy services to effectively provide
treatment, care, and/or services in order to improve the enrollee's level of function, to establish/perform a
maintenance program to maintain the enrollee's level of function and/or prevent deterioration. The enrollee
should be able to transition to an independent home exercise program and her functional level does not require
ongoing skilled therapy 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 12 additional HH PT visits have not been met. Therefore, we decided that the
Plan does not have to pre-approve 12 additional home health (HH) physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 95951) provided on September 6, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service
cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or
provider must corroborate the documentation in the beneficiary's medical documentation and confirm that
Medicare coverage criteria have been met.
We looked at the file and Medicare rules. The documentation submitted by the non-contract provider does not
contain records for the date of service in question. Without these records, it cannot be determined that Medicare
coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the services (CPT
95951) provided on September 6, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that the enrollee would benefit from a short
stay in the SNF with daily therapy. The Plan denied your request. The Plan says the enrollee's needs are
custodial.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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 the SNF admission. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee is a female who was
admitted to the hospital due to syncope. From a nursing perspective, the beneficiary received oral medications
and insulin. The beneficiary had stable vital signs. She was alert with confusion. Her lungs were clear.
Regarding rehabilitation services, the beneficiary received PT and OT in the acute hospital. The beneficiary
was required contact guard to minimal assist with ADLs including gait to 120 feet with a rolling walker. The
beneficiary required varying with ADLs.
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs;
however, skilled therapy is not required on a daily basis. This beneficiary does not meet severity of illness or
intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the SNF admission have not been met. Therefore, we decided that the Plan does
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis rendered on December 30, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an LSO is covered when specific 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the submitted documentation does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee. The documentation does not support that the spinal orthosis was ordered for one of the following indications: to reduce pain by restricting mobility of the trunk, to facilitate healing following an injury to the spine or related soft tissues, to facilitate healing following a surgical procedure on the spine or related soft tissue, or to otherwise support weak spinal muscles and/or a deformed spine. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis rendered on December 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient clinic visit (G0463) and the x-ray exam of the chest (71046) rendered by the out of network (OON) provider on November 17, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services were provided by an out of network provider, without prior authorization.
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 in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve these services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the outpatient clinic visit (G0463) and the x-ray exam of the chest (71046) rendered by the out of network (OON) provider on November 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the automatic external defibrillator provided on November
30, 2019.
You asked the Plan to pay for the automatic external defibrillator (K0606). You say that the automatic external
defibrillator was medically necessary. The Plan denied your request. The Plan says durable medical equipment
is not paid separately when the enrollee is an inpatient.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate
and needed for use inside the home. Medicare does not consider a hospital to be a home.
Records show that the automatic external defibrillator (K0606) was used in a hospital. Therefore, we decided
that the Plan does not have to pay for the automatic external defibrillator provided on November 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a cystourethroscopy provided on December 23, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for a cystourethroscopy. You say that these services were medically necessary. You
say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The
Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide 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 a cystourethroscopy provided on December 23,
2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health services.
You asked the Plan to pre-approve inpatient mental health services. You say that the services are necessary.
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not
been met.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or
provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare
coverage criteria have been met.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of inpatient mental health services have not been met. Specifically, medical records were not
provided. Without this documentation, medical necessity is not able to be established. Therefore, we decided
that the Plan does not have to pre-approve inpatient mental health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided from
September 19, 2019 to November 19, 2019.
You asked the Plan to waive the coinsurance for DME and related supplies. You say that your responsibility is
not clear. The Plan denied your request. The Plan says the claims were processed correctly and you are being
charged the correct amount.
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 DME and related supplies.
You received DME and related supplies on September 19, 2019. The total allowed amount is $431.96 and 20%
of that is $86.40.
You received DME and related supplies on October 19, 2019. The total allowed amount is $273.56 and 20% of
that is $54.71.
You received DME and related supplies on November 19, 2019. The total allowed amount is $273.56 and 20%
of that is $54.71.
The total amount you owe is: $195.82.
You have been asked to pay the total coinsurance amount of $195.82 for DME and related supplies. DME and
related supplies fall within the DME and related supplies benefit category. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the coinsurance for DME and related supplies provided from September 19, 2019 to November 19,
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (CPT 95999) provided to the enrollee on
August 20, 2019.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request.
The Plan says this service is considered a bundled procedure as the cost is included in the cost of the primary
procedure.
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 95999 is "unlisted neurological or neuromuscular
diagnostic procedure."
We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the
services at issue in this case were not coded correctly. Our coding reviewer found train of four testing is being
billed separately, using code 95999. This procedure is included with the primary service, and billing separately
would be considered unbundling.
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 testing have not been met. Therefore, we decided that the Plan does not have
to pay for train of four testing (CPT 95999) provided to the enrollee on August 20, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for Myocardial Perfusion Imaging (78452) provided September 10, 2019.
You asked the Plan to pay for the Myocardial Perfusion Imaging. You say that the services were medically
necessary. The Plan denied your request. The Plan says that the records provided do not support the services
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. In this case, the CPT Code Manual definition of
code 78452 is Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction,
qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional
quantification, when performed) multiple studies, at rest and/or stress (exercise or pharmacologic) and/or
redistribution and/or rest reinjection.
We find that CPT code 78452 is supported in the medical record. Specifically, a review of the records
determined that the records support the study billed. Based on this information, we decided that Medicare rules
for coverage of the Myocardial Perfusion Imaging have been met. Therefore, we decided that the Plan has to
pay for Myocardial Perfusion Imaging (78452) provided September 10, 2019.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel Sureclick.
You asked the Plan to pre-approve Enbrel Sureclick. You say that you would like the Plan to reconsider their
denial. The Plan denied your request. The Plan says Enbrel Sureclick is not covered by the enrollee's Medicare
Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Enbrel Sureclick.
Benefits for Enbrel Sureclick 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Benlysta injections.
You asked the Plan to pre-approve the Benlysta treatments. You say that the enrollee should be allowed this
treatment as other medications have failed to help. The Plan denied your request. The Plan says this medication
cannot be covered unless it is used in conjunction with standard lupus treatments.
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 the Benlysta treatments. Our reviewer
says that the requested treatment is not considered reasonable and necessary in this case. Our physician
reviewer found the enrollee is a 59 year old female diagnosed with systemic lupus erythematosus manifested
by positive autoantibodies and arthritis. There is documentation that the enrollee has not tolerated Plaquenil or
Methotrexate secondary to adverse side effects, however these side effects are not clearly documented. In the
most recent progress report from 05/2020, the enrollee is complaining of migratory joint pain, at times present
in her knees and shoulders. Other current rheumatologic medications are not documented. The treatment plan is
for Benlysta.
Benlysta may be recommended in conjunction with other studied therapies for the treatment of active, mild to
moderately active, autoantibody positive systemic lupus in conjunction with other standard lupus therapy. In
this case, there is inadequate documentation to support mild to moderate disease activity of systemic lupus.
Additionally, there is no documentation of intent to use Benlysta in combination with other standard lupus
therapies such as Plaquenil and Prednisone. On the basis of this lack of documentation the request for Benlysta
does not meet required criteria.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the Benlysta treatments have not been met. Therefore, we decided that the Plan
does not have to pre-approve Benlysta injections.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on November 19, 2019 by
an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that your provider cannot deny any medical
services that were essential for patient health treatment. The Plan denied your request. The Plan says the
referring facility is out-of-network. The Plan says that no prior authorization was obtained.
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 has network providers
available who can provide 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 skilled nursing services provided on November
19, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on
October 9, 2019.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you disagree with the
$17.37 charge because you did not receive services. The Plan denied your request. The Plan says the claims
were processed correctly and you are being charged the correct amount.
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 received Medicare Part B drugs on October 9, 2019. The total allowed amount is $86.88 and 20% of that
is $17.37.
You have been asked to pay the total coinsurance amount of $17.37 for Medicare Part B drugs. Medicare Part
B drugs fall 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. Therefore, we decided that the Plan does not have
to waive the coinsurance for Medicare Part B drugs provided on October 9, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the observation stay provided from July 18,
2019 through July 20, 2019.
You asked the Plan to waive the copayment for the observation stay. You say that you were admitted to the
hospital. You say that the bill should be paid. The Plan denied your request. The Plan says the copayment
applied 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 $100
copayment for outpatient hospital observation services.
You have been asked to pay a $100 copayment for the observation stay. The observation stay falls within the
"Outpatient hospital services" benefit category. The records show that you were admitted to outpatient
observation. This means that you have been asked to pay the correct amount based on your contract with the
Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore,
we decided that the Plan does not have to waive the copayment for the observation stay provided from July 18,
2019 through July 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on
November 26, 2019.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you asked the
provider's office if they accepted your insurance and they told you yes. You also say that you were in severe
pain and unable to eat which required you seeing the dentist. The Plan denied your request. The Plan says you
exceeded the limits set in the subscriber agreement.
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, exams are limited to two procedures
per plan year. The record shows that you received a problem focused limited oral evaluation on May 1, 2019
and a periodic oral evaluation on August 23, 2019 and your exams benefit was then exhausted. Therefore, we
decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on
November 26, 2019.