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

 
We decided that the Plan does not have to pay for the emergency department visit coded 99285 provided on 
January 13, 2020. 
 
You asked the Plan to pay for the emergency department visit. 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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function. 
   
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 emergency department visit. Our coding 
reviewer found the documentation does not support CPT 99285 to include comprehensive history, 
comprehensive examination and Medical decision making of high complexity. Medical Decision Making is 
Moderate Complexity with 3 data reviewed.  There is a more appropriate code for services performed. 
 
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 emergency department visit have not been met. Therefore, we decided that 
the Plan does not have to pay for the emergency department visit coded 99285 provided on January 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tetanus, diphtheria toxoids and acellular pertussis vaccine 
(Tdap), when administered to individuals 7 years or older, for intramuscular use (CPT Code 90715) provided 
on June 22, 2020. 
 
You asked the Plan to pay for the tetanus vaccine. You say that you should not be responsible for the cost of 
this vaccine. The Plan denied your request. The Plan says the Part B Tetanus vaccine is only payable when 
related to treatment of an injury or direct exposure to a disease or condition and the claim did not contain any 
such diagnosis. In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the 
tetanus vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly 
exposed to any illness related to the tetanus vaccine. A Tetanus vaccine is only payable when related to 
treatment of an injury or direct exposure to a disease or condition. The claim did not contain any such 
diagnosis. Therefore, we decided that the Plan does not have to pay for tetanus, diphtheria toxoids and acellular 
pertussis vaccine (Tdap), when administered to individuals 7 years or older, for intramuscular use (CPT Code 
90715) provided on June 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
treated in acute care for pneumonia, pancreatitis with septic shock, respiratory and kidney failure. He has been 
discharged to skilled nursing where he is receiving rehabilitation services. Medical conditions are stable. There 
are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The 
patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for 
physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There 
is not a reasonable expectation that this patient 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Lab services (80061, 83036, 84443) provided July 11, 2019. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be covered. The Plan denied your request. The Plan says the services billed are non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 80061-GY, 83036-GY, and 84443-GY are not supported in the record. Specifically, 
the codes billed included the GY modifier. Codes are billed with the GY modifier when the provider has 
determined they do not meet Medicare coverage criteria. Based on this information, we decided that Medicare 
rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to 
pay for Lab services (80061, 83036, 84443) provided July 11, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on April 10, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 10, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on April 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an X-ray provided on July 28, 2020. 
 
You asked the Plan to waive the copayment for an X-ray. You say that you disagree with the charges because 
you were not aware of them and cannot afford them. 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 $100 
copayment for basic radiology services provided in an outpatient hospital facility. 
 
You received an X-ray at an outpatient hospital facility on July 28, 2020. Therefore, you are responsible to pay 
the allowed amount of $76.64, which is less than the $100 copayment.   
 
You have been asked to pay $76.64 for an X-ray. An X-ray 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 X-ray provided on July 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rituximab (Q5119). 
 
You asked the Plan to pre-approve Rituximab. You say that this treatment is medically necessary. The Plan 
denied your request. The Plan says rules for pre-approval have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Rituximab. Our reviewer says that 
Rituximab is not medically necessary. Our physician reviewer found that this appeal considers the medical 
necessity for the requested Rituximab for the treatment of autoimmune hemolytic anemia. Submitted 
documentation, Medicare guidelines, and Medicare approved compendia were considered. Review of the 
compendia does not support Rituximab for this diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Rituximab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Rituximab (Q5119).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durvalumab. 
 
You asked the Plan to pre-approve Durvalumab. You say that the requested Durvalumab is medically 
necessary. The Plan denied your request. The Plan says the requested Durvalumab is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Durvalumab. Our reviewer says that the 
requested Durvalumab is not medically necessary. Our physician reviewer found the enrollee is diagnosed with 
non-small cell lung cancer. The FDA has not approved Durvalumab for the treatment of unresectable stage 3 
non-small cell lung cancer in adults whose disease has not progressed following concurrent platinum-based 
chemotherapy and radiation therapy. This enrollee is eligible to receive chemoRT given stage and positive 
margins and then durvalumab would be reasonable if no progression. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durvalumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Durvalumab.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray provided on August 19, 2020. 
 
You asked the Plan to waive the copayment for an X-ray. You say that you disagree with the charges because 
you should not owe a copayment for the service. 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 $110 
copayment for basic radiological services for outpatient hospital services.  
 
The record shows that you received an X-ray at an outpatient hospital facility on August 19, 2020. Therefore, 
you are responsible to pay the allowed amount of $107.31. 
 
You have been asked to pay $107.31 for an X-ray. An X-ray falls within the outpatient hospital services 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 X-ray provided on August 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mobile x-ray services rendered on June 12, 2020. 
 
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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 3 represents TC only codes. 
 
We looked at the file and Medicare rules. The provider submitted a claim for procedure code R0070. This code 
has a PC/TC indicator of 3 and no PC payment. Therefore, we decided that the Plan does not have to pay for 
the mobile x-ray services rendered on June 12, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services rendered on June 4, 2020. 
 
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 enrollee was on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on June 3, 2020. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the services rendered on 
June 4, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an EGD and a diagnostic colonoscopy 
provided on September 18, 2020. 
 
You asked the Plan to waive the copayments for an EGD and a diagnostic colonoscopy. You say that you were 
told that you would only owe a $35 copayment. 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 $250 
copayment for each outpatient surgery for outpatient hospital services.  
 
You received an EGD on September 18, 2020. Therefore, you are responsible to pay the $250 copayment.  
 
You received a diagnostic colonoscopy on September 18, 2020. Therefore, you are responsible to pay the 
allowed amount of $184.29, which is less than the $250 copayment.  
 
The total amount you owe is: $434.29.  
 
You have been asked to pay the total copayment amount of $434.29 for an EGD and a diagnostic colonoscopy. 
An EGD and a diagnostic colonoscopy fall within the outpatient hospital services 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 copayments for an EGD and a diagnostic colonoscopy provided on September 18, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic care. 
 
You asked the Plan to pre-approve chiropractic care. You say that the requested chiropractic care is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
chiropractic care. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
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 chiropractic care Our reviewer says that 
the enrollee does not meet criteria for the requested chiropractic care. Our physician reviewer found the only 
treatment allowed by Medicare for chiropractors is to treat a subluxation of the spine. The subluxation may be 
demonstrated by x-ray or by physical examination. If the subluxation is demonstrated by physical examination, 
it must include: pain/tenderness evaluated in terms of location, quality and intensity; asymmetry/misalignment 
identified on a sectional or segmental level; range of motion abnormality (changes in active, passive and 
accessory joint movements resulting in an increase or a decrease of sectional or segmental mobility); and, 
tissue, tone changes in the characteristics of contiguous or associated soft tissues including skin, fascia, muscle 
and ligament. There are no submitted imaging studies to reveal evidence of a subluxation. The submitted, 
handwritten, chart note/office visit note dated 11/12/20, reveals no evidence of any objective findings, with an 
assessment of lumbar spinal misalignment causing leg pain and numbness and a plan for lumbar/sacrum x-rays. 
There is no evidence of subluxation per Medicare guidelines. Thus, chiropractic treatment is neither supported 
nor allowed per Medicare guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of chiropractic care have not been met. Therefore, we decided that the Plan does 
not have to pre-approve chiropractic care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health care visits. 
 
You asked the Plan to pre-approve home health care visits. You say that the additional home health care visits 
are medically necessary. The Plan denied your request. The Plan says the additional home health care visits are 
not medically necessary. 
 
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 home health care visits. Our reviewer 
says that the additional home health care visits are not medically necessary. Our physician reviewer found the 
records do not show that skilled nursing services are required to effectively provide treatment, care, and/or 
services in order to improve the enrollee's condition, or to establish/perform a maintenance program to 
maintain the enrollee's condition and/or prevent deterioration. The enrollee and caregiver have had colostomy 
care education. There is no evidence of complex wound care or other ongoing SN need. The enrollee's needs do 
not require ongoing professional skilled nursing 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 home health care visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health care visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Continuous Positive Airway Pressure (CPAP) 
machine. 
 
You asked the Plan to pre-approve the CPAP. You say that the claim should be paid. The Plan denied your 
request. The Plan says you did not meet the minimum requirement of usage for continued coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that ?adherence to therapy isdefined as use of PAP 
greater than or equal to 4 hours per night on at least 70% of nights during a consecutive thirty day period 
anytime during the first three months of initial usage. The provided compliance reports are not from within the 
first three months of usage, and do not show use of the device for at least four hours per night for 70% of nights 
during a consecutive 30-day period.   
 
 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CPAP have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Continuous Positive Airway Pressure (CPAP) machine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a segmental pneumatic compressor (E0652). 
 
You asked the Plan to pre-approve the pneumatic compression device. You say that you would like 
reconsideration because the member will benefit to better control their symptoms and avoid recurrent cellulitis. 
The Plan denied your request. The Plan says the member does not have lymphedema that extends into the 
chest, trunk, and/or abdomen, the member has not met the coverage criteria for E0650or E0651, and the 
member has not had a failed response to treatment with E0650 or E0651. 
 
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 pneumatic compression device.  
 
 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the documentation does not characterize the edema in detail enough to 
confirm severity and does not include a lower extremity physical exam. In addition, there is no documented 
trial of medication such as a diuretic where appropriate and there is no documentation that the edema extends 
into the chest, trunk or abdomen. 
 
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 pneumatic compression device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a segmental pneumatic compressor (E0652).