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

We decided that the Plan does not have to pay for the drug testing services provided on May 15, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 11. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 57. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on May 15, 2019.
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 the enrollee would be better served with 
his clinical complexities in an LTACH setting. The Plan denied your request. The Plan says that the member is 
receiving appropriate in-patient acute care. 
 
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 enrollee 
does not require services at the LTACH that are not available at the acute care hospital where he is currently 
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tendonesis (23430), repair of ruptured musculotendinous cuff 
(23412) and capsular contracture release (23020) provided on February 21, 2018. 
 
You asked the Plan to pay for the surgery. You say that you would like reconsideration because payment 
should be made to this provider as well. The Plan denied your request. The Plan says the services are all 
included in CPT code 23472. 
 
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 coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the surgery. Our reviewer says that CPT codes 23430, 23412 
and 23020 do not meet criteria for billing or reimbursement consideration. Our reviewer found billing CPT 
23430, 23412 and 23020 with CPT 23472 is considered "unbundling procedures" CPT codes 23430, 23412 and 
23020 is all inclusive to CPT 23472, and therefore, not separately billable. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pay for tendonesis (23430), repair of ruptured musculotendinous cuff (23412) and capsular contracture 
release (23020) provided on February 21, 2018.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve right knee arthroscopy surgery.
You asked the Plan to pre-approve knee surgery. You say that you are requesting that the plan allow this surgery. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because this surgery is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 knee surgery. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee presents with complaints of right knee pain with intermitted swelling around the patella. Functional limitations are noted in activities of daily living. She is post-left knee surgery with good improvement in pain. She has not been able to tolerate physical therapy or exercise. Arthroscopic surgery was recommended as an attempt to forestall or avoid distal femoral osteotomy in this enrollee who may not understand the severity of the surgery and recovery. The evidence-based medical literature supports the requested surgery to treat patellar articular surface for pain reduction and functional restoration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of knee surgery have been met. Therefore, we decided that the Plan has to pre-approve right knee arthroscopy surgery.
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services could be provided in another setting, such as acute rehab 
facility, skilled nursing facility, nursing facility, outpatient setting, or home care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is currently undergoing treatment at an ACH for coronary artery disease. 
The enrollee underwent a coronary bypass, after which she was quickly extubated. The enrollee was only 
recently reintubated/ventilated. The enrollee does not yet have a tracheotomy. The documentation does not yet 
show failed weaning. The enrollee's long-term care plan/goals is/are not clear. There is no evidence that the 
enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the 
same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at 
the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged 
to a lower level of care for any ongoing long term care needs. 
 
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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from December 29, 
2019 to December 31, 2019. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee 
did not need skilled medical care or skilled nursing care during this time. 
 
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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from December 29, 2019 to December 31, 
2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary for the 
enrollee. The Plan denied your request. The Plan says that the member's condition appears to be custodial in 
nature. 
 
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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3, 
 
You asked the Plan to pre-approve the Gelsyn-3. You say that you would like reconsideration because this drug 
is medically necessary. The Plan denied your request. The Plan says you do not meet step therapy exception 
criteria. 
 
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 the Gelsyn-3. Our reviewer says that 
you have not tried and failed the Plan's required drugs. Our physician reviewer found there is no documentation 
provided indicating that Orthovisc and Monovisc would likely be less effective and/or have adverse effects. 
 
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 Gelsyn-3 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gelsyn-3,
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lower extremity orthoses (L1970, L2820, L2275x2, L2220) provided on February 26, 2020.
You asked the Plan to pay for the lower extremity orthoses. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery.
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. 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 lower extremity orthoses (L1970, L2820, L2275x2, L2220) provided on February 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex spacer. 
 
You asked the Plan to pre-approve the Vertiflex spacer. You say that you would like reconsideration because 
this device will eliminate pain when walking and bending over. The Plan denied your request. The Plan says 
you do not meet coverage criteria for 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 Vertiflex spacer. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this device is experimental and more research is needed to show its 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 Vertiflex spacer have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex spacer.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the surgery provided on April 7, 2020. 
 
You asked the Plan to waive the coinsurance for the surgery. You say that you are disabled and cannot afford 
the same-day surgery amount. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing 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 30% 
coinsurance for each covered surgery or observation room service in an outpatient hospital.  
 
You have been asked to pay $3,987.07 which is 30% of the allowed amount for the surgery. The allowed 
amount is $13,290.24. ($13,290.24 x 30% = $3,987.07). The medical record shows you were considered and 
outpatient. The surgery falls within the ?Outpatient surgery, including services provided at hospital outpatient 
facilities and ambulatory surgical centers? 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 the surgery provided on April 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture and mandibular partial 
denture. 
 
You asked the Plan to pre-approve the maxillary and mandibular partial dentures. You say that you just got 
Medicaid and were informed you could get dentures. The Plan denied your request. The Plan says your plan 
does not provide coverage for upper and lower partial dentures. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
maxillary partial denture and mandibular partial denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high pressure intermittent arterial compression pump for the enrollee.
You asked the Plan to pre-approve the pump. You say that this is medically necessary. The Plan denied your request. The Plan says a pneumatic compression device for peripheral artery disease is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that a PCD coded as E0675 to treat PAD is not a covered benefit. The requested device is statutorily not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the pump have not been met. Therefore, we decided that the Plan does not have to pre-approve a high pressure intermittent arterial compression pump for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that these are medically necessary. The 
Plan denied your request. The Plan says that these are not covered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve B12 shots. 
 
You asked the Plan to pre-approve the B12 shots. You say that you would like reconsideration because your 
B12 levels are decreasing. The Plan denied your request. The Plan says this service is 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 the B12 shots. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you do not have a low B-12 level and your symptoms are not consistent with Vitamin B-12 
deficiency. 
 
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 B12 shots have not been met. Therefore, we decided that the Plan does not 
have to pre-approve B12 shots.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 30, 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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for an 
independent laboratory; however, the file shows that the specimen was obtained in an office setting and should 
have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on January 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on February 28, 2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one 
unit of CPT 81479 and the appropriate DEX Z-Code.  
 
We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT 
codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-
Code. 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 the Guardant360 testing provided on February 28, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed (item code E0303). 
 
You asked the Plan to pre-approve heavy duty extra wide hospital bed. You say that the enrollee's conditions 
make the enrollee uncomfortable in a regular position bed, so you recommend this bed. The Plan denied your 
request. The Plan says the denial of authorization for this item is correct, because the enrollee does not meet the 
weight criteria for the requested heavy duty extra wide hospital bed. 
 
The Plan must follow Medicare rules. Medicare rules say that heavy duty extra wide hospital beds are only 
covered when the enrollee's weight is more than 350 pounds but does not exceed 600 pounds.  
 
We looked at the file and Medicare rules. The enrollee's weight is less than 350 pounds, therefore the enrollee 
does not meet the Medicare criteria for this bed. Based on this information, we decided that Medicare rules for 
coverage of heavy duty extra wide hospital bed have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a heavy duty extra wide hospital bed (item code E0303).