Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on April 1, 2020. 
 
You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the item rendered is not supported by the 
documentation. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file 
shows that the documentation did not include an itemized shipping/billing invoice to indicate the specific 
supplies or proof of delivery for the billed date of service. The submitted invoice indicates the item was 
shipped on March 16, 2020 and delivered on March 18, 2020. 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 the lumbar-sacral orthosis provided on April 1, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health care provided to the enrollee on 
January 30, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 contract states outpatient mental health requires a 
referral.  
 
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 the service 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 outpatient mental health care provided to the enrollee on January 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or 
heat exchanger (99190) provided on March 25, 2020. 
 
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger. 
You say that this was a necessary service. The Plan denied your request. The Plan says payment for this service 
is included in the DRG. 
 
 
 
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that 
CMS designates to be inpatient-only services. These services have an OPPS status indicator of C in the 
OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule.  
 
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of 
C on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as 
inpatient only, and therefore must be billed as part of an inpatient admission. Therefore, we decided that the 
Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger 
(99190) provided on March 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transfer handles/a transit kit (K0108). 
 
You asked the Plan to pre-approve transfer handles/a transit kit. You say that the enrollee needs these items. 
The Plan denied your request. The Plan says this is for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve transfer handles/a transit kit (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral or facial photographic image (D0350) provided on 
January 2, 2020. 
 
You asked the Plan to pay for the oral or facial photographic image. You say that the provider office opened a 
medical line of credit in your name. You say that you signed an authorization because the provider was out of 
network. You also say that you have no money, no credit and no teeth. The Plan denied your request. The Plan 
says oral or facial photographic image is not listed as a covered service. 
 
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 oral or facial photographic image is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
oral or facial photographic image (D0350) provided on January 2, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health care provided to the enrollee out of 
network on February 27, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 contract says specifically states outpatient mental 
health requires a referral. 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 
the service 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 outpatient mental health care provided to the enrollee out of 
network on February 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane (J7318). 
 
You asked the Plan to pre-approve Durolane. You say that Durolane is medically necessary. The Plan denied 
your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives can be considered. 
 
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 Durolane. Our reviewer says that 
Durolane is not medically necessary. Our physician reviewer found the record does not show a trial of the plan 
preferred drugs or any reason the plan preferred drugs would be unsafe or ineffective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane (J7318).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular junction testing coded 95937 provided on 
February 5, 2019. 
 
You asked the Plan to pay for the neuromuscular junction testing. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
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 95937 is neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method. 
 
We find that CPT code 95937 is not supported in the medical record. Specifically, the documentation submitted 
does not support that neuromuscular junction testing was performed. The documentation supports that Train of 
Four Testing/Monitoring was performed which does not meet the guidelines of CPT code 95937. Based on this 
information, we decided that Medicare rules for coverage of the neuromuscular junction testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the neuromuscular junction testing coded 
95937 provided on February 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tegaderm thin film provided to the enrollee on 
September 9, 2019. 
 
You asked the Plan to pay for these services. You say that this was medically necessary. The Plan denied your 
request. The Plan says this is not covered because the enrollee was in a SNF. 
 
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 SNF or a hospital to be a home.  
 
Records show that these services was used in a SNF or hospital. Therefore, we decided that the Plan does not 
have to pay for the Tegaderm thin film provided to the enrollee on September 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the six office visits to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve office visits. You say that you were referred to this provider. The Plan 
denied your request. The Plan says there are in-network providers that can perform this service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the six office visits to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee is receiving appropriate care at the current acute 
care facility. 
 
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. The patient 
appears to be improving but is likely to require more than 24 additional days of acute care services which can 
be completed at the current setting. The patient does not require services at the LTACH that are not already 
available at the current hospital. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for LTACH services. 
 
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 for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance (eg, proton) imaging 
(MRI) any joint of lower extremity (78721-LT) provided March 18, 2020. 
 
You asked the Plan to waive the copayment for the MRI. You say that the wrong MRI was ordered and 
performed and you paid the copay. You do not believe you should have to pay the copay for the second MRI 
because it was due to incorrect ordering in the first place. The Plan denied your request. The Plan says the 
claim processed correctly and the correct copayment was applied per the plan benefits. 
 
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 $150 
copayment for Medicare covered diagnostic radiology services.  
 
You have been asked to pay $150 copayment for the MRI. The MRI falls within the Outpatient diagnostic tests 
and therapeutic services and 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 copayment for 
magnetic resonance (eg, proton) imaging (MRI) any joint of lower extremity (78721-LT) provided March 18, 
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on 
January 14, 2020. 
 
You asked the Plan to pay for the drug testing. You say that this was medically necessary testing. The Plan 
denied your request. The Plan says there is no valid order for this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when it is ordered by 
a treating provider. 
 
In this case, the order provided does not state specifically which drug classes should be tested. The order is also 
unsigned, though it notes that a signature is on file, but the form does not indicate the ordering provider clearly 
so it cannot be determined that the signature on file matches the ordering physician. Therefore, we decided that 
the Plan does not have to pay for the presumptive and definitive drug testing provided on January 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient behavioral health services provided July 3, 2020 
to July 10, 2020. 
 
You asked the Plan to pay for the inpatient behavioral health services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 the inpatient behavioral health services. Our 
reviewer says that the services rendered are not medically necessary. Our physician reviewer found the enrollee 
was admitted to the acute inpatient psychiatric hospitalization Major Depressive Disorder, Recurrent, Severe, 
 
 
Cocaine Use Disorder, Severe and Alcohol Use Disorder, Moderate. Based upon review the records provided it 
was not expected this enrollee would improve in a reasonable period of time as the enrollee did not have 
dangerousness to self or others, auditory or visual hallucinations, delusions and was not showing any 
behavioral issues. It did not appear medically necessary and reasonable to have psychiatric care provided at the 
acute inpatient level of care rather than a lower level of care as the enrollee did not have dangerousness to self 
or others, perceptual disturbance including delusions, auditory or visual hallucinations. Therefore, the enrollee 
did not meet criteria for the services rendered. 
 
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 inpatient behavioral health services have not been met. Therefore, we 
decided that the Plan does not have to pay for the inpatient behavioral health services provided July 3, 2020 to 
July 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous and/or interlaminar device for the 
enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says more research is needed to determine efficacy of this device. 
 
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 the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the device is experimental. More research is needed to show safety and efficacy. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an interspinous and/or interlaminar device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5226). 
 
You asked the Plan to pre-approve the mandibular partial denture. The Plan denied your request. The Plan says 
this service exceeds the maximum count allowed per period. 
 
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, mandibular dentures are limited to one 
procedure every five plan years. The record shows that you received a mandibular partial denture (D5214) on 
July 24, 2018, and your mandibular denture benefit has been exhausted. Therefore, we decided that the Plan 
does not have to pre-approve a mandibular partial denture (D5226).
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 admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled 
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to 
safely and effectively provide medically necessary and reasonable treatment in a SNF.  The enrollee does not 
have complex wound care or other ongoing SNF level SN need. The enrollee's functional level does not require 
skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely 
 
 
and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require 
skilled nursing or skilled therapy services (or a combination of these services) on a daily basis in a SNF. As a 
practical matter, this enrollee does not require the necessary services on 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 admission to a SNF 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on April 2, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that telemedicine does not require prior authorization. The 
Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services 
rendered by an out-of-network provider. 
 
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 the office visit (99214) provided on April 2, 2020 
by an out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio. 
 
You asked the Plan to pre-approve Entyvio. You say that the requested Entyvio is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Remicade OR Inflectra; AND Stelara. 
 
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 Entyvio. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee is with a diagnosis of 
ulcerative colitis. He has failed treatment with Humira and Xeljanz; Entyvio injections have been requested. 
Based on the medical records provided the enrollee has not tried and failed the required Plan drug(s). Based on 
the medical records provided there is no indication that the Plan's required drug(s) would likely be less 
effective and/or likely have adverse effects for the enrollee. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio.