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

We decided that the Plan does not have to pay for the new patient office or other outpatient visit (99205) 
provided on April 22, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the new patient office or other outpatient visit. You say that you would like this 
claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization 
was not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 new patient office or other outpatient visit 
(99205) provided on April 22, 2020, by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology services provided on July 15, 2020. 
 
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says 
all services provided by out-of-network providers requires prior authorization except for emergency, urgent 
care or dialysis while temporarily out of the plan's service area.  
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for diagnostic radiology services provided on July 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for epoetin alfa (Procrit) provided on April 22, 2020. 
 
You asked the Plan to pay for Procrit. You say that Procrit was supplied and administered by your provider; 
therefore, you should be paid. The Plan denied your request. The Plan says the denial of payment for this drug 
is correct, because the enrollee's hemoglobin level was above 10 Gm and there was no documentation of 
Ferritin, Bone Marrow Iron stain, or Transferrin saturation. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for Procrit. Our reviewer says that the Procrit 
provided does not meet the Medicare criteria for coverage. Our physician reviewer found there was no clinical 
rationale for the Procrit given on April 22, 2020. The enrollee's hemoglobin level was above 10 Gm at 10.9 
Gm. There was no documentation of Ferritin, Bone Marrow Iron stain, or Transferrin saturation. The requested 
use of epoetin alfa is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. Its use 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 Procrit have not been met. Therefore, we decided that the Plan does not have to 
pay for epoetin alfa (Procrit) provided on April 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the device was necessary to 
prevent deep vein thrombosis. The Plan denied your request. The Plan says the pneumatic compression device 
is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to pay for a pneumatic compression device (E0676).
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not 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. You were admitted for 
septic shock, colitis, and respiratory failure. Medical problems are stable. There are no identified problems that 
need inpatient medical management. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. The medical record supports a need for physical and occupational therapy, but 
it does not support a need for an intensive rehabilitation therapy program. 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an EKG provided by a participating 
provider on June 29, 2020. 
 
You asked the Plan to waive the copayment for an EKG. You say that no one told you that you would have a 
copayment for this. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 
copayment for outpatient diagnostic tests/diagnostic radiological services/echocardiography.  
 
You have been asked to pay $18.74 which is less than your copayment amount of $25 for an EKG. An EKG 
falls within the outpatient diagnostic tests/diagnostic radiological services/echocardiography benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an EKG provided by a participating provider on June 29, 
2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sterile water, supplies for maintenance of non-insulin 
drug infusion catheter, and infusion supplies for external drug infusion pump provided from December 9, 2019 
to December 31, 2019. 
 
You asked the Plan to pay for the sterile water, supplies for maintenance of non-insulin drug infusion catheter, 
and infusion supplies for external drug infusion pump. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says there was no delivery sheet submitted with the claim. 
 
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 for the supplies provided in this case. Review of the file 
does not include a delivery sheet for the billed date of service range for the supplies provided. 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 the sterile water, supplies for maintenance of non-
insulin drug infusion catheter, and infusion supplies for external drug infusion pump provided from December 
9, 2019 to December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the copaymentsfor the debridement of subcutaneous tissue (11042) and the wound debridement (97597) provided on April 23, 2020, and April 30, 2020.You asked the Plan to adjust the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the copayments have been applied correctly to the services provided.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 $335 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay $440.12 ($284.52+ $155.60) for the Medicare-covered servicesprovided to you at theoutpatient hospital. Thisis the Plan allowed amountwhich is less than the applicable copayments for these services. 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 adjust the copaymentsfor the debridement of subcutaneous tissue (11042) and the wound debridement (97597) provided onApril 23, 2020,and April 30, 2020. Your complaint about being overcharged for the services provided is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the partial removal of bone with release of spinal cord or 
spinal nerves in upper or lower spine (63035-AS-50) provided on March 11, 2020. 
 
You asked the Plan to pay for the partial removal of bone with release of spinal cord or spinal nerves in upper 
or lower spine. You say that the care provided was medically necessary. The Plan denied your request. The 
Plan says the Add-On Code was not eligible for payment as the primary code was not eligible for payment. 
 
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 63035-AS-50 is the partial removal of bone with release 
of spinal cord or spinal nerves in upper or lower spine. 
 
We find that CPT code 63035-AS-50 is not supported in the medical record. Specifically, this is an add-on 
code that must be billed with an appropriate primary procedure code. The record indicates that the primary 
procedure code was denied, which means the add-on code is not currently eligible for separate payment. Based 
on this information, we decided that Medicare rules for coverage of the partial removal of bone with release of 
spinal cord or spinal nerves in upper or lower spine (63035-AS-50) have not been met. Therefore, we decided 
that the Plan does not have to pay for the partial removal of bone with release of spinal cord or spinal nerves in 
upper or lower spine (63035-AS-50) provided on March 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the placement of an amniotic membrane on the eye provided 
on February 12, 2020. 
 
You asked the Plan to pay for the membrane placement. You say that the records show that these codes should 
be paid. The Plan denied your request. The Plan says the visit noted was amended to include more information 
but this was not done in accordance with the Recordkeeping Principles. 
 
The Plan must follow Medicare rules. Medicare rules say that amendments or delayed entries/addenda to 
medical records must be clearly identified as such and clearly indicate who made the addition and when this 
was added.  
 
In this case, the original visit note received did not include adequate documentation of the placement of the 
membrane. The visit note that was subsequently submitted, including additional information but there was 
nothing identifying the additional information as an addendum and no documentation of the author of the 
addendum or when it was added. As such, this information in the note cannot be used for medical review 
purposes to support payment of the code at issue. Therefore, we decided that the Plan does not have to pay for 
the placement of an amniotic membrane on the eye provided on February 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility visit (99308) provided on May 13, 2020, 
by an out of network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility visit. You say that the visits are not pre-
scheduled; therefore, an authorization was not obtained prior to the services provided. The Plan denied your 
request. The Plan says prior authorization was not obtained by the facility or the provider; therefore, payment 
has been correctly denied. 
 
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 nursing facility visit (99308) provided on May 
13, 2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on February 11, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider 
on February 11, 2020.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for continued SNF services provided from April 6, 2020, to May 5, 2020. 
 
You asked the Plan to pay for the SNF care. 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 that medical necessity 
cannot be established for continued stay at the SNF during this time. 
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal. 
 
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or 
more days before April 5, 2020. The Plan must pay for SNF services until the 100-day SNF care benefit is 
exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the 
Plan has to pay for continued SNF services provided from April 6, 2020, to May 5, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for closed treatment of posterior pelvic ring fracture (27197) 
provided March 3, 2020. 
 
You asked the Plan to pay for closed treatment of pelvic ring fracture. You say that please review the medical 
records provided. The medical records clearly indicated that the enrollee has an acute left sacral fracture as 
indicated by the MRI results. Please reprocess the claim. The Plan denied your request. The Plan says the 
records do not support the billed service. 
 
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 21797 is Closed treatment of posterior pelvic ring 
fracture(S), dislocation(S), and diastasis or subluxation of the ilium, sacroiliac joint, and /or dislocation(S) of 
the pubic symphysis and/or superior/inferior rami, unilateral or bilateral; without manipulation. 
 
We find that CPT code 21797 is not supported in the medical record. Specifically, the submitted medical 
records do not include documentation of a closed treatment of posterior pelvic ring fracture(s), dislocation(s), 
diastasis or subluxation of the ilium, sacroiliac joint, and/or sacrum, with or without anterior pelvic ring 
fracture(s) and/or dislocation(s) of the pubic symphysis and/or superior/inferior rami, unilateral or bilateral; 
without manipulation as being performed.  
 
Based on this information, we decided that Medicare rules for coverage of closed treatment of pelvic ring 
fracture have not been met. Therefore, we decided that the Plan does not have to pay for closed treatment of 
posterior pelvic ring fracture (27197) provided March 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided April 13, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the orthosis was medically necessary. The Plan denied 
your request. The Plan says the enrollee already received this type of orthosis. 
 
The Plan must follow Medicare rules. Medicare rules say that carriers may determine the reasonable useful 
lifetime of equipment but in no case can it be less than 5 years.  
 
We looked at the file and Medicare rules. The record shows the enrollee received this type of Orthosis in 2018. 
The record does not include documentation showing the orthosis the enrollee already received was irreparably 
damaged or otherwise needed replacement. A new wrist-hand orthosis is not supported by the documents 
provided. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been 
met. Therefore, we decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided April 
13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs HF System. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of NYSHA 
Class III congestive heart failure with variable left ventricular ejection fraction requiring hospitalization, most 
recently 55 percent in June of 2020. In this circumstance, therapy change based on data obtained from a 
CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to 
standard medical therapy. The services are considered experimental or investigational and are not reasonable or 
medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CardioMEMs HF System.