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

 
We decided that the Plan does not have to pay for the colonoscopy (45378) and preparation with instillation of 
fecal microbiota (G0455) provided on February 19, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for colonoscopy and fecal microbiota. You say that the services rendered were 
medically necessary. The Plan denied your request. The Plan says they require utilization of network providers 
when possible and available, and requires authorization for certain services. No medical necessity for an out-of-
network provider, such as an urgent or emergency situation, has been documented. 
 
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 colonoscopy (45378) and preparation with 
instillation of fecal microbiota (G0455) provided on February 19, 2020 by an out of network (OON) provider.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Radiation Therapy for Bone Metastases (CPT Codes: 
77412 x5, 77295, 77263, 77280, 77290, 77293, 77295, 77300 x 10, 77332, 77334 x10, 77336 x7, 77417 x7, 
77427 x7, 77470, 77387, 77014). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says there is no current research showing that the enrollee's type of cancer responds better to 
the requested type of treatment than the type of treatment the Plan can approve. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Plan should deny IGRT. Per NCCN radiation compendia, would approve EBRT and IMRT 
only. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Radiation Therapy for Bone Metastases (CPT Codes: 77412 x5, 77295, 77263, 77280, 
77290, 77293, 77295, 77300 x 10, 77332, 77334 x10, 77336 x7, 77417 x7, 77427 x7, 77470, 77387, 77014).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on June 4, 2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that this was a visit for a routine eye 
exam. You say that nothing was done outside of a routine eye exam which should have no cost. The Plan 
denied your request. The Plan says the copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for specialist visits. 
 
You have been asked to pay a $20 copayment for the office visit. The office visit falls within the "Vision care" 
benefit category. The records show that cataracts, presbyopia and hyperopia were discussed during the office 
visit, which is not considered a routine exam. 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 office 
visit provided on June 4, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the assay of somatomedin provided on April 29, 2020. 
 
You asked the Plan to pay for the somatomedin assay. You say that the lab results do show results for both 
83003 and 84305. The Plan denied your request. The Plan says that there is no lab result for a somatomedin 
assay. 
 
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 84305 is assay of somatomedin. 
 
We find that CPT code 84305 is supported in the medical record. Specifically, the lab report shows a result for 
IGF-1 which is synonymous with somatomedin. Based on this information, we decided that Medicare rules for 
coverage of the somatomedin assay have been met. Therefore, we decided that the Plan has to pay for the assay 
of somatomedin provided on April 29, 2020.  
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the documentation fails to indicate that you require medical practitioner 
assessment or intervention at least 3 times a week, specialized therapeutic skills or equipment, and 
rehabilitation nursing services 24 hours a day. 
 
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. There 
is no evidence of medical issues that require monitoring by an inpatient rehab physician three times a week. 
The documentation does not support that there is a need for an intensive therapy program with 3 hours a day 
and an interdisciplinary approach to rehab care. You were recently discharged from a skilled nursing facility 
and do not require IRF care for the same problem. Your rehab needs can be met in an alternate, less intense 
setting. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.  
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you need this equipment to get in and out of 
the shower safely. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the physical therapy services provided on 
August 25, 2020. 
 
You asked the Plan to waive the copay for the services provided. You say that the services should be covered. 
The Plan denied your request. The Plan says the claim processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copay for outpatient rehab services.  
 
You have been asked to pay a $25 copay for the physical therapy services provided. The services fall within the 
outpatient rehab 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 copay for the physical 
therapy services provided on August 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CardioMEMS implant for the enrollee.
You asked the Plan to pre-approve the implant. You say that this is medically necessary. The Plan denied your
request. The Plan says the available evidence does not show that this service is effective or provides better
health outcomes.
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 implant. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found in this circumstance therapy change based on data obtained from a CardioMEMS device has been
demonstrated in only one randomized prospective trial to help reduce hospital readmission compared to
standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into
question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to
leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare
coverage criteria are not met since the device should still be considered experimental or investigational.
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 implant have not been met. Therefore, we decided that the Plan does not
have to pre-approve the CardioMEMS implant for the enrollee.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Privigen (J1459).
You asked the Plan to pre-approve Privigen. You say that Privigen is what is available. The Plan denied your
request. The Plan says that this drug is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Privigen. Our reviewer says that
Privigen is medically reasonable and necessary for the enrollee. Our physician reviewer found the
documentation supports that Privigen (J1459) is safe and effective 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 Privigen have been met. Therefore, we decided that the Plan has to pre-approve
Privigen (J1459).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that you are in a lot of pain and need rehab badly.The Plan denied your request. The Plan says criteria for admission to the Acute Inpatient Rehabilitation setting have not been met.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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that you do not require treatment by multiple therapies, including eitherphysical 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. Our physician reviewer also found that there is not a reasonable expectation that you 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-approveacute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe Vertiflex device for the enrollee.You asked the Planto pre-approvethe device. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is a lack ofscientific evidence regarding the effectiveness 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 spacer is experimental. More research is needed to show safety and efficacy. There is no spinal instability documented. The hardware is not needed. The spacer is not medically needed.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 Plandoes not haveto pre-approvethe Vertiflex device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 27096) provided on June 25, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
payable. 
 
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 code 27096 is not payable in this case. Specifically, CPT code 27096 is not payable under 
the OPPS. 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 services (CPT 27096) provided on 
June 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an initial consultation for a second opinion to be 
provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve an initial consultation for a second opinion. You say that you would like the 
Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither 
emergent nor urgent to seek out-of-network care. The Plan says there are equally qualified in-network 
providers available to you that can provide the services you are requesting. 
 
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 
an initial consultation for a second opinion to be provided by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home ventilator (E0466) provided on April 30, 2020. 
 
You asked the Plan to pay for a home ventilator. You say that the service should be covered. The Plan denied 
your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered 
services related or unrelated to the member?s terminal condition. The Medicare hospice benefit, through fee-
for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or 
revocation. During the election, fee-for-service Medicare also covers attending physician services and all care 
unrelated to the terminal illness until the first day of the month following the month in which hospice was 
revoked or discharged. 
 
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 April 22, 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 a home ventilator 
(E0466) provided on April 30, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the home health aide provided from June 22, 
2020, to July 2, 2020. 
 
You asked the Plan to reimburse you for the home health aide. You say that you had hip replacement surgery. 
You say that you live alone. You say that you were unable to get a bed at a rehabilitation facility due to Covid-
19. You say that you needed assistance with getting in and out of bed as well as using the bathroom. The Plan 
denied your request. The Plan says home health aide services are not covered unless it is associated with skilled 
nursing facility (SNF) services at this time. The Plan says that there was no prior authorization for the services. 
The Plan also says the provider for the home health aide services is out of network.  
 
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.  
 
The file shows that skilled nursing or therapy services were not provided during the dates of service at issue in 
this appeal. Therefore, we decided that the Plan does not have to reimburse you for the home health aide 
provided from June 22, 2020, to July 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency ambulance transport (A0427) 
provided on June 8, 2020. 
 
You asked the Plan to waive the copayment for emergency ambulance transport. You say that the service 
should be covered. The Plan denied your request. The Plan says the cost share was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment for each one-way Medicare-covered ground trip for ambulance services.  
 
You have been asked to pay a $225 copayment for each one-way Medicare-covered ground trip for emergency 
ambulance transport. This service falls within the ambulance 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 emergency ambulance transport (A0427) provided on June 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the risk assessment panel provided on August 25, 2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that all CV risk assessment panels, except the basic 
lipid panel, are denied for symptomatic (with signs and symptoms) patients with suspected or documented CV 
disease because panel testing is not specific to a given patient's lipid abnormality or disease.  
 
We looked at the file and Medicare rules. Per L36523, the requested risk assessment panel is non-covered. 
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 risk assessment panel provided on August 25, 
2020.