Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 25605) provided on November 27, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the MUE for this 
service as been exceeded. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 25605 is 1. You billed 2 units of this code, exceeding the MUE. 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 25605) provided on November 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging services provided on September 5, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation and confirm that 
Medicare coverage criteria have been met.  
 
We looked at the file and Medicare rules. The services were billed with POS code 31, which indicates that the 
enrollee was in a Part A covered stay. If that were the case, then the setup and transport would not be billable to 
the plan by the provider, but by the SNF. This means that reporting POS code 31 is not appropriate. 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 imaging services provided on September 5, 2020.
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 you need rehab. The Plan denied your request. The 
Plan says the services are 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 medically necessary. Our physician reviewer found the records show that you were 
admitted to the hospital on February 1, 2021. The therapy notes dated February 8, 2021 states you need 
assistance with bed rolling, standing up, and bed mobility. The records do not snow that you need the intensity 
of services provided at an IRF. Specifically, you do not need 15 hours per week of rehabilitation services with 
regular physician evaluation. 
 
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: Surgery
Decision: Favorable

We decided that the Plan has to apply in-network cost sharing for the percutaneous catheter stent placement 
provided on September 11, 2020 billed with code 92928. 
 
You asked the Plan to apply in-network cost sharing for the surgical service. You say that you feel this should 
be covered as in-network since the services were provided in an in-network facility. The Plan denied your 
request. The Plan says that it was decided to apply in-network cost sharing for the services described by code 
93948. However, the denial of code 92928 was correct since the claim was a duplicate. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided with the surgical service within a contract facility. The file does not show that the Plan 
provided notice that the surgical service would not be covered. Under Medicare rules, this means the surgical 
service is considered approved by the Plan. Although there was a duplicate claim submitted, the paid claim 
processed incorrectly with OON cost sharing, which the Plan attested would be incorrect due the inpatient stay 
in the participating facility. Therefore, we decided that the Plan has to apply in-network cost sharing for the 
percutaneous catheter stent placement provided on September 11, 2020 billed with code 92928.  
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on July 29, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until September 18, 2020. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the services provided on July 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture treatments. 
 
You asked the Plan to pre-approve the requested acupuncture treatments. You say that you need this treatment 
and feel it should be covered. The Plan denied your request. The Plan says the requested provider is not 
Medica-certified. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments when rendered by certain types of providers.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the requested provider is not a physician, physician 
assistant, or nurse practitioner/clinical nurse specialist. There is also no evidence that these services would be 
provided under the general supervision of one of these provider types. Therefore, we decided that the Plan does 
not have to pre-approve acupuncture treatments.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Imfinzi. 
 
You asked the Plan to pre-approve the Imfinzi. You say that you would like reconsideration because this drug 
is medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare 
criteria for coverage. 
 
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 the Imfinzi. Our reviewer says that 
based on the medical records provided there is no documentation that the Imfinzi is medically reasonable and 
necessary for the member as the records do not document that her disease has not progressed following 
concurrent platinum-based chemotherapy and radiation therapy. Our physician reviewer found there is no 
documentation that the Imfinzi is safe and effective for the member. 
 
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 Imfinzi have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Imfinzi.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Avastin (bevacizumab).

You asked the Plan to pre-approve Avastin. You say that the enrollee has had worsening symptoms and disease progression with poor tolerance to medication. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because Avastin is not supported for use with carcinoid tumors and may be considered experimental/investigational.

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 Avastin. Our reviewer says that the enrollee does not meet the Medicare criteria for use of Avastin. Our physician reviewer found Avastin is not approved for the enrollee's condition. The requested use of Avastin in this case is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Avastin have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Avastin (bevacizumab).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy. 
 
You asked the Plan to pre-approve the requested services. You say that proton beam therapy is better able to 
concentrate the radiation in the target. The Plan denied your request. The Plan says there is no benefit for the 
use of proton beam therapy over intensity modulated radiation therapy (IMRT). 
 
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 requested services. Our physician 
reviewer found that there is no clear evidence that proton beam therapy for prostate cancer offers any clinical 
advantage over other forms of definitive radiation therapy. Clinical trials are necessary to establish a possible 
advantage of this expensive therapy. Nothing in the case file suggests that consensus (NCCN, QUANTEC) 
constraints cannot be met with the non-proton based treatment, and it is not plausible that proton therapy would 
be needed to meet these constraints. Simply demonstrating that proton therapy will reduce the low dose to 
normal tissues does not necessarily demonstrate that it is clinically 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam radiation therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ongoing peritoneal dialysis services to be provided by an out of network (OON) dialysis center.

You asked the Plan to pre-approve the OON peritoneal dialysis services. You say that the enrollee is an established patient with this provider and would like to continue. The Plan denied your request. The Plan says the requested OON care is not medically necessary because it is for convenience. There are network providers available.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few exceptions, enrollees must use contract providers for 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 OON peritoneal dialysis services. Our reviewer says that the documentation does not support that ongoing care (beyond those visits approved) from the OON provider is medically necessary. Our physician reviewer found the services requested are available in the area, and there appear to be no special circumstances that would warrant the out of network provider. The use of an OON provider cannot be justified based on the information reviewed.

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 OON peritoneal dialysis services have not been met. Therefore, we decided that the Plan does not have to pre-approve ongoing peritoneal dialysis services to be provided by an out of network (OON) dialysis center.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray (71045) provided on August 9, 2020. 
 
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration because this service 
was rendered in the appropriate place of service. The Plan denied your request. The Plan says the member was 
inpatient on the billed date of service 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 71045 is not supported in the record. Specifically, the record indicates that the member 
was registered inpatient on the billed date of service. It is not appropriate to bill an outpatient place of service 
code when the member is registered inpatient. Based on this information, we decided that Medicare rules for 
coverage of the chest x-ray have not been met. Therefore, we decided that the Plan does not have to pay for the 
chest x-ray (71045) provided on August 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve an office visit to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says the services can be provided by an in-network provider. Therefore, coverage criteria has not been met.

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 office visit to be provided by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the air ambulance services (A0431-II, A0436-II) provided on August 15, 2020.

You asked the Plan to pay for the air ambulance services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says Medicare only covers air transport to hospital.

The Plan must follow Medicare rules. Medicare rules say that coverage is only available to a facility that is an acute care hospital. 

We looked at the file and Medicare rules. The file indicates that the services were billed with the modifier (II) which indicates the transport from site of transfer to site of transfer. Based on this information, we decided that Medicare rules for coverage of the air ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the air ambulance services (A0431-II, A0436-II) provided on August 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prostate artery embolization. 
 
You asked the Plan to pre-approve prostate artery embolization. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
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 prostate artery embolization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested service is considered experimental and investigational and is 
therefore not medically necessary and reasonable as defined by Medicare law. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prostate artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve prostate artery embolization.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve the repair of a power wheelchair.

You asked the Plan to pre-approve the repairs. You say that you would like reconsideration because the scooter is something that you need to have as functioning in order for you to be operational. The Plan denied your request. The Plan says that Medicare criteria are not met for the power wheelchair repair.

The Plan must follow Medicare rules. Medicare rules say that if the expense for repairs exceeds the estimated expense of purchasing or renting another item of equipment for the remaining period of medical need, no payment can be made for the amount of the excess. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the repairs have been met. Specifically, the Plan is responsible for payment of the repairs up to the cost of a replacement. Therefore, we decided that the Plan has to pre-approve the repair of a power wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care (99222) provided July 12, 2019.

You asked the Plan to pay for the initial hospital care. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the claim was received past the allowed 12-month timeframe.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the initial hospital care was not filed until November 3, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the initial hospital care (99222) provided July 12, 2019.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve tissue growth removal for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says that there was no documentation of tenderness, inflammation or change in size 
from prior evaluation. 
 
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 the procedure. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee was symptomatic with the growths on her back and noticed enlargement and discomfort 
over a several month period. Excision is medically standard and reasonable when the mass lesions were 
causing symptoms. 
 
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 procedure have been met. Therefore, we decided that the Plan has to pre-
approve tissue growth removal for the enrollee.  
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam provided by on June 5, 2020.

You asked the Plan to waive the copayment for the medical eye exam. You say that you would like the insurance to cover the charge. 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 a $50 copayment for Medicare-covered vision services. 

You have been asked to pay a $50 copayment for the medical eye exam. The medical eye exam falls within the "Vision care" 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 the medical eye exam provided on June 5, 2020.