Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance provided on August 27, 2020. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you cannot afford to pay for this 
service. The Plan denied your request. The Plan says this service is not covered. 
 
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 pay for the 
periodontal maintenance provided on August 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the facility fees provided from January 29, 
2020, to February 17, 2020. 
 
You asked the Plan to waive the copayments for the facility fees. You say that you have been charged the 
correct cost sharing amount. The Plan denied your request. The Plan says that the hospital did not provide any 
services on these dates of service.  
 
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 $275 
copayment for Medicare-covered outpatient hospital and observation services. For each date of service, you 
have been asked to pay the allowed amount of the claim because these amounts are less than the $275 
copayment for the facility fee. 
 
You have been asked to pay a $103.93 copayment for the facility fee on each date of service. The facility fees 
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 the facility fees provided from January 29, 2020, to February 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dupixent pen (J3590). 
 
You asked the Plan to pre-approve a Dupixent pen. You say that other medications do not control the enrollee's 
condition. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the 
enrollee's prescription drug plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve a Dupixent pen (J3590).  
 
Benefits for a Dupixent pen may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you are not ready to be discharged. The Plan 
denied your request. The Plan says that your benefit will exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period. The 
Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve continued skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp injections. 
 
You asked the Plan to pre-approve the Aranesp treatment. You say that you feel that this should be allowed to 
treat the enrollee's anemia. The Plan denied your request. The Plan says this is noncovered. 
 
The Plan follows Medicare rules. Medicare rules say that ESA treatment, such as with Aranesp, is nationally 
noncovered for enrollees with anemia caused by bone marrow fibrosis. 
 
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 Aranesp treatment. Our reviewer 
says that the requested treatment is not considered reasonable and necessary and is requested for a nationally 
noncovered indication. Our physician reviewer found the records do support that the enrollee's anemia is 
caused for bone marrow fibrosis. Bone marrow fibrosis is a central pathological feature and WHO diagnostic 
criterion for the diagnosis of myelofibrosis. Given this, Medicare does not allow payment for this treatment 
when the enrollee has these findings. 
 
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 Aranesp treatment have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Aranesp injections.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided. 
 
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the 
clinical utility of the testing could not be determined. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. Based on this information, we decided that 
Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan 
does not have to pay for the drug testing services provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99222) provided on July 28, 2020. 
 
You asked the Plan to pay for the initial hospital care. You say that you would like reconsideration because this 
service was incorrectly denied as bundled. The Plan denied your request. The Plan says this claim was not 
billed with an appropriate modifier. 
 
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, we have confirmed that code the 
initial hospital care has a bundled relationship with code 31624 and cannot be paid as billed.  
 
 
 
 
The claim has not been billed with the required modifier to indicate that these services were significant and 
separately identifiable. This code cannot be paid as a separate line item. Based on the claim submitted, 
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for initial 
hospital care (99222) provided on July 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right knee genicular nerve radiofrequency ablation for 
the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the evidence for this request is promising but not proven at this time. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this procedure is still considered experimental and investigational and is the subject of on-going clinical 
trials. The procedure is not part of established treatment algorithms. Therefore, the request is considered not 
medically reasonable or necessary. 
 
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 right knee genicular nerve radiofrequency ablation for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this transfer is medically necessary. The 
Plan denied your request. The Plan says Medicare coverage criteria for transfer are not met. 
 
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 
Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not 
provide clinical services that are materially different than those of short-term acute care hospitals. In this case, 
ongoing care needs include ventilatory weaning, tracheostomy care, radiology studies with indicated 
thoracentesis, oral anticoagulation,  surveillance laboratory studies, tube feedings, and therapy services. 
The documentation does not support that the enrollee in this case requires services at the LTACH that are not 
available at the acute care hospital where he is currently receiving care. Consequently, the requested LTACH 
services are not medically necessary, reasonable, and appropriate at this time. We looked at this physician's 
review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 
the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long 
term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is only covered when enrolled in a clinical study. 
 
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 enrollee presents with a 5-year history of low back and bilateral leg pain. Signs/symptoms are 
reported consistent with neurogenic claudication. There is imaging evidence of severe central canal and 
moderate neuroforaminal stenosis at L2/3, moderate central canal stenosis at L3/4, and moderate to severe left 
neuroforaminal stenosis at L4/5. The physician reported severe stenosis at 2 levels due to epidural lipomatosis. 
She has reportedly failed long-term conservative treatment. Under consideration is a request for Vertiflex 
interspinous device at L2/3 and L3/4. Current evidence based medical guideline and peer reviewed literature do 
not fully support the spinal decompression device procedure over the gold standard f lumbar laminectomy. 
There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for 
this enrollees medical condition as discussed above. FDA indications include implantation of the Superion 
device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative 
treatment is indicated at no more than two levels, from L1 to L5. This enrollee has at least moderate spinal 
stenosis at L2/3, L3/4 and L4/5, severe at the L2/3 level, and would not meet FDA indications. FDA 
contraindications include obesity and osteoporosis, and have not been adequately addressed in the medical 
records. There is no documentation of the enrollees height, weight or body mass index with significant 
epidural lipomatosis documented. There is no discussion indicating that a DEXA scan has demonstrated no 
osteoporosis in this 56-year-old female. Superion indirect lumbar decompression would not be considered the 
standard of care for the enrolles medical condition. Therefore, this request does not meet Medicare criteria as 
medically reasonable and necessary for treatment of this enrollees medical condition. 
 
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 Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer (J1439). 
 
You asked the Plan to pre-approve Injectafer. You say that Injectafer is medically necessary. The Plan denied 
your request. The Plan says a trial of oral iron is required before alternatives like Injectafer can be considered. 
 
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 Injectafer. Our reviewer says that 
Injectafer is not medically necessary. Our physician reviewer found the record shows no trial of the plan's 
preferred drugs or any reason why they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer (J1439).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of the brain rendered 
on September 16, 2019. 
 
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 procedure code 70553 is not supported. 
 
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 70553 is magnetic resonance (eg, proton) imaging, brain 
(including brain stem); without contrast material, followed by contrast material(s) and further sequences. 
 
We find that CPT code 70553 is not supported in the medical record. Specifically, the records support the 
billing of one unit of this code, which has been paid by the Plan. There is no documentation to support billing 
of further units of this code. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the magnetic 
resonance imaging (MRI) of the brain rendered on September 16, 2019.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a computed tomography (CT) scan (74176) provided on September 27, 
2020. 
 
You asked the Plan to pay for a CT scan. You say that this code is supported by the records. The Plan denied 
your request. The Plan says that this procedure requires a modifier due to NCCI edits. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. The rules also say that MACs subject all line items for the same beneficiary, same NPI, and same 
date of service to NCCI edits. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that this service denied due to NCCI edits; however, the paid 
code was rendered by a different provider. The case file and NPI numbers do not substantiate that this provider 
is in the same group practice. Therefore, we decided that the Plan has to pay for a computed tomography (CT) 
scan (74176) provided on September 27, 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the positron emission tomography (PET) scan rendered on June 1, 
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 that the diagnosis is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
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 pay for these services. Our reviewer says that the 
services were medically necessary. Our physician reviewer found the enrollee has known metastatic lung 
cancer to the bone and underwent a PET scan for restaging of a non-small cell lung cancer to determine 
subsequent treatment strategies. The PET scan was reasonable and medically necessary for this 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 these services have been met. Therefore, we decided that the Plan has to pay for 
the positron emission tomography (PET) scan rendered on June 1, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan coded 75571 provided. 
 
You asked the Plan to pay for the CT scan. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 75571 is computed tomography, heart, without contrast 
material, with quantitative evaluation of coronary calcium. 
 
We find that CPT code 75571 is not supported in the medical record. Specifically, this claim was not billed 
correctly. All charges except for telehealth originating site facility fee, PPV, influenza virus vaccine, hepatitis 
B vaccine and hospital-based ambulance services are combined and reported under a certain revenue code on a 
certain type of bill code. The claim must be billed with a revenue code of 0510 an a type of bill of 13X. Based 
on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, 
we decided that the Plan does not have to pay for the CT scan coded 75571 provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in network rate for the complete series of x-rays (D0210) 
provided on August 27, 2020. 
 
You asked the Plan to pay the in network rate for the complete series of x-rays. You say that you called to find 
the closest dental office. You say that you were given the number for this dental office. You say that you 
advised the dentist to only do what insurance would cover. You also say that you received a bill that you do not 
owe. The Plan denied your request. The Plan says the complete series of x-rays is not listed and therefore is not 
a covered service. 
 
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 pay the in 
network rate for the complete series of x-rays (D0210) provided on August 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from July 28, 2020, to 
July 29, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that you were not allowed to bring any 
medications with you, and were required to use the hospital's medications. The Plan denied your request. The 
Plan says self-administered drugs are not covered under Part B of Original Medicare. The Plan also says that 
the self-administered drugs are not covered under the medical benefits under your plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided from July 28, 2020, to July 29, 2020.