Persius/hicric huggingface dataset:
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 clinical documentation provided 
supports the need for care in an LTACH. The Plan denied your request. The Plan says the enrollee can receive 
all of the care required at the current 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 was admitted to the acute care hospital on October 19, 2020 with 
pneumonia. Testing for Covid-19 was positive. The enrollee underwent multiple thoracentesis procedures to 
drain a pleural effusion. The enrollee was placed on BiPAP for respiratory failure and antibiotics were 
administered. The enrollee was transiently hypotensive on December 17 and December 18, 2020. It was 
documented that the enrollee "is actually a candidate for hospice." Ultrafiltration has been poorly tolerated due 
to hypotension. The discharge plan is for a psychiatry unit when the enrollee is medically cleared. The enrollee 
is receiving acute hospital care, and acute care services have not been denied. The documentation does not 
support that the enrollee in this case requires services at the LTACH that are not available at the acute care 
hospital where he is currently receiving care. Consequently, the requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-invasive home ventilator. 
 
You asked the Plan to pre-approve a non-invasive home ventilator. You say that the requested device is 
essential therapy needed. You say that BiPAP and CPAP is insufficient due to the severity of the enrollee's 
condition. You say that, without the support of the requested device, the enrollee may go into respiratory 
failure. The Plan denied your request. The Plan says the information provided does not show that a BiPAP 
machine did not work for the enrollee at home when she was not sick. The Plan says that the information must 
show that the enrollee cannot use this machine at home before they can approve the ventilator requested. The 
Plan says that there were no reports showing the enrollee is using her current machine as directed. 
 
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 non-invasive home ventilator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has chronic obstructive pulmonary disease, but an arterial 
blood gas shows a normal pCO2 of 39. Thus, there is no need for, or expected benefit from, ventilatory support 
at night. A home ventilator is not medically necessary and the criteria for coverage have not been met. 
 
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 non-invasive home ventilator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a non-invasive home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Novocure electrical stimulation  device  used  for  
cancer  treatment (E0766). 
 
You asked the Plan to pre-approve the electrical stimulation device. You say that Novocure is FDA approved 
based on the scientific evidence and the health outcomes are as good or better than usual treatments. The Plan 
denied your request. The Plan says under Medicare rules the request is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that this treatment is only approved when there is newly 
diagnosed, supratentorial GBM among other rules.  
 
 
 
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 electrical stimulation device. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found you do not have a 
newly diagnosed glioblastoma multiforme (GBM) of the top part of the brain. 
 
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 electrical stimulation device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Novocure electrical stimulation  device  used  for  cancer  treatment 
(E0766).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gammagard (J1569) infusions to be provided 
. 
 
You asked the Plan to pre-approve the infusions. You say that the enrollee has been without IVIG treatment for 
2 months. You say that this has resulted in increased pain, impaired balance for the enrollee. You say that you 
recently moved because he is not able to tolerate cold weather secondary to his condition. The 
Plan denied your request. The Plan says he enrollee has an authorization to receive treatment from an in 
network provider in Idaho. The Plan also says that there is no medical necessity the enrollee needs to receive 
treatment out of state. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
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 infusions. Our reviewer says that 
the request to receive this service out of the Plan's service area is not medically necessary. Our physician 
reviewer found the enrollee has foreseen leaving the Plan's service area.  
 
 
 
 
The reviewer found that this is a change in location that was elective and would have been planned in advance, 
therefore, the change in location was not emergent or unexpected. The reviewer found that while the member is 
noted to have received IVIG for 2 months, his condition is not one that requires immediate treatment at this 
time. The reviewer found that the enrollee's care could otherwise wait until his new plan takes effect to restart 
therapy. Therefore, the reviewer found that the requested service is not medically reasonable or necessary to 
receive out of the Plan's service area. 
 
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 infusions have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gammagard (J1569) infusions to be provided
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation accessory, an expandable 
controller, and a harness. 
 
You asked the Plan to pre-approve a power seat elevation accessory, an expandable controller, and a harness. 
You say that the requested power wheelchair is needed for the enrollee to safely and efficiently complete his 
activities of daily living. The Plan denied your request. The Plan says the items which remain in dispute are 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 power seat elevation accessory, an 
expandable controller, and a harness. Our reviewer says that the requested items are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic inflammatory 
demyelinating polyneuropathy (CIDP) and generalized muscle weakness, as well as diabetes and hypertension. 
The problem list includes pressure injury of skin of the coccygeal region.  The documentation does not support 
that a power seat elevation accessory, an expandable controller, and a harness are medically reasonable and 
necessary for the enrollee in this case. The documentation does not support that the requested items are 
necessary to perform activities of daily living in the home. There is not a medical need for an expandable 
controller and harness to control power options through a joystick. 
 
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 power seat elevation accessory, an expandable controller, and a harness have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation 
accessory, an expandable controller, and a harness.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided from July 8, 2020, through 
July 15, 2020, by an out-of-network provider. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says prior authorization was not obtained by the provider or facility. 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 medical services provided from 
July 8, 2020, through July 15, 2020, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
March 6, 2020, through March 11, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $300 
copayment per day, for days 1-5 and a $0 copayment per day for additional days, for in-network inpatient 
hospital care.  
 
You have been asked to pay $1,500 ($300 copayment x 5 days) for the in-network inpatient hospital care 
provided. 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 inpatient hospital care provided from  
March 6, 2020, through March 11, 2020.
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 there is no clinical advantage of LTACH over acute 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. The patient 
appears to not yet be stable and requires short term additional acute care hospital services which can be 
completed at the current facility. The patient does not require services at the LTACH that are not already 
available at the current facility. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee. 
 
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 that this claim denied because this claim was billed with place of service (POS) code of 
22 (outpatient). According to the claim history, the enrollee was an inpatient. The medical records received 
do not mention the status of the enrollee and 
do not contradict what was found in claims history for the enrollee.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the POS code reported on the claim is 
contradicted by the enrollees claim history. Medicare billing criteria were not met. Therefore, we decided that 
the Plan does not have to pay for physician services provided to the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services you received at an outpatient 
hospital facility. 
 
You asked the Plan to waive the copayment for the lab services. You say that you were not made aware of this 
charge. The Plan denied your request. The Plan says you were charged this amount correctly. The Plan also 
says that because the allowed amount for these labs ($13.47) is less than the allowed amount, you are 
responsible for the full cost. 
 
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 $15 
copayment for lab services in an outpatient hospital.  
 
You have been asked to pay a $15 copayment for the lab services. 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 lab services you received at an outpatient hospital facility. Please note that 
this decision is limited to the lab services on date of service.  Your appeal letter to the Plan 
references other dates of service.  Please contact the Plan directly regarding the other dates of service.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services provided to the enrollee on May 
19, 2020, by a Registered Nurse First Assistant (RNFA). 
 
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 services were performed by an Assistant (RNFA). Although skilled, an RNFA is not 
recognized for payment by CMS. Surgical assistants actively assist the physician performing a surgical 
procedure. Reimbursement for surgical assistant services is based on whether the assistant is a Physician or 
other health care professional. Medicare Part B pays for services provided by physicians and certain 
nonphysician practitioners, such as nurse practitioners, physician assistants and clinical nurse specialists. Other 
categories of non-physician practitioners are not recognized as Medicare providers and thus are not able to bill 
the program independently for their services. Medicare cannot reimburse a surgical assistant's services if the 
assistant is an unlicensed practitioner and/or does not qualify to be a Medicare provider. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant 
service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when 
provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for 
surgical assistant services provided to the enrollee on May 19, 2020, by a Registered Nurse First Assistant 
(RNFA).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ECG provided on July 28, 2020. 
 
You asked the Plan to waive the copayment for an ECG. You say that the ECG was part of a specialist visit and 
you should not be responsible for the charges. 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 a $30 
copayment for non-radiological diagnostic services. 
 
You received an ECG on July 28, 2020. An ECG is subject to separate cost-sharing charges from a specialist 
visit. Therefore, you are responsible to pay the allowed amount of $12.60, which is less than the $30 
copayment.  
 
You have been asked to pay $12.60 for an ECG. An ECG 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 
an ECG provided on July 28, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of the nerve conduction studies (NCS) and 
electromyography (EMG) provided during a surgical procedure on June 8, 2020 billed with codes 95909-26 
and 95886-26. 
 
You asked the Plan to pay for the NCS/EMG. You say that these codes are supported and should be paid. The 
Plan denied your request. The Plan says the billed codes are not documented in the records. 
 
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 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 NCS/EMG. Our reviewer says that the 
documentation does not support the billed codes. Our coding reviewer found the provided procedure report 
does not include documentation of 5-6 Nerve Conduction studies. CPT 95886 is an "add-on" code and is not 
reimbursable if primary code (95909) is denied. 
 
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 NCS/EMG have not been met. Therefore, we decided that the Plan does not 
have to pay for the interpretation of the nerve conduction studies (NCS) and electromyography (EMG) 
provided during a surgical procedure on June 8, 2020 billed with codes 95909-26 and 95886-26.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction services (92015) provided on July 27, 
2020. 
 
You asked the Plan to pay for the eye refraction services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says eye refraction services are a non-
covered service unless performed as a routine eye exam. 
 
 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are performed during a routine eye exam. 
 
We looked at the file and the Plan's rules. The file indicates that you received the eye refraction services not as 
part of a routine eye exam but as part of a diabetic eye exam. Based on this information, we decided that the 
Plan's rules for coverage of the eye refraction services have not been met. Therefore, we decided that the Plan 
does not have to pay for the eye refraction services (92015) provided on July 27, 2020.