Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to make additional payment for the psychological services provided on 
May 18, 2020. 
 
You asked the Plan to make additional payment for the psychological services. You say that you paid $190 for 
this visit and expect that you should be reimbursed $140 since you have a $50 copayment. There is nothing in 
the contract which says what the Plan's reimbursement would be if you pay out of pocket and submit a claim to 
be reimbursed. The Plan denied your request. The Plan says the allowed amount for the service at issue is 
$78.43. You were reimbursed the difference between this amount and your $50 copayment. 
 
The Plan must follow Medicare rules. Medicare rules say that non-contract providers enrolled in Medicare 
must accept Original Medicare payment rates as payment in full.  
 
In this case, $78.43 is considered payment in full for the service at issue. The Plan correctly issued 
reimbursement for the amount that exceeds your $50 copayment. Although the contract does not clearly state 
what the reimbursement would be in this situation, the Plan is not required to pay out more than Original 
Medicare would pay for a service. Therefore, we decided that the Plan does not have to make additional 
payment for the psychological services provided on May 18, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee needs to be 
monitored after her procedure and ensure proper care. The Plan denied your request. The Plan says that that the 
care can be provided without an inpatient stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for acute inpatient hospital care are met in this 
case. It is reasonable to think that a wound infection and/or cellulitis requiring hospitalization and intravenous 
antibiotics would require at least 2 midnights. Our physician reviewer found that the enrollee's condition meets 
Medicare criteria for acute inpatient hospital 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pre-approve acute inpatient hospital care.  
 
 
 
 
 
 
 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove a pneumatic compression device (E0651). 
 
You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee did not use home 
therapy because it did not control symptoms. The Plan denied your request. The Plan says the documentation 
failed to prove that sufficient evidence of four-week trial of conservative therapy. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0651 is covered for the treatment of The 
rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema 
and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. A four-week trial of 
conservative therapy demonstrating failed response to treatment is required. 
 
 
 
 
 
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, the record does not show that the enrollee had at least 
four weeks of regular home usage of conservative therapy including compression garments, exercise and 
elevation. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device 
(E0651).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Boniva for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
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 Boniva for the enrollee.  
 
Benefits for this drug 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractor services to be performed by an out-of-
network provider. 
 
You asked the Plan to pre-approve chiropractor services. You say that the services are necessary. The Plan 
denied your request. The Plan says there are providers available in the Plan network that can provide the 
services. 
 
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 
chiropractor services to be performed by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral evaluation, bitewings, and prophylaxis 
provided on June 16, 2020 by an OON provider. 
 
You asked the Plan to pay more for the periodic oral evaluation, bitewings, and prophylaxis. You say that the 
information summary plan document indicates that the coverage is the same for in-network and OON 
providers, which is why you did not look for an in-network provider. The Plan denied your request. The Plan 
says the OON liability was applied correctly per your plan benefits. 
 
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, you are responsible for the difference 
between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay more 
for the periodic oral evaluation, bitewings, and prophylaxis provided on June 16, 2020 by an OON provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to further pay for the emergency room services provided on February 
21, 2020. 
 
You asked the Plan to further pay for the services provided. You say that the services are coded according to 
the services provided. The Plan denied your request. The Plan says the documentation does not support the 
billed services. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. 
 
We find that CPT code 99285 is not supported in the medical record. The records show that the enrollee 
presented with abdominal pain, with a decision to take over the counter medications, and follow up with his 
primary care provider. The medical records provided do not support a high complexity of decision making care 
was provided. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to further pay for the emergency room services provided on 
February 21, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on March 3, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing 
rendered on March 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methotrexate tablets. 
 
You asked the Plan to pre-approve Methotrexate tablets. You say that the enrollee has been taking 
Methotrexate since October 30, 2019, and her condition is stable. You also say that the enrollee is not 
experiencing any side effects. The Plan denied your request. The Plan says this drug is a self-administered 
drug, and is not covered under the enrollee's medical benefit. 
 
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 Methotrexate tablets.  
 
Benefits for Methotrexate tablets 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resection of the small intestine billed for services 
provided on December 27, 2019. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed 
services cannot be verified. 
 
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 44120 is enterectomy, resection of small intestine; single 
resection and anastomosis. We find that CPT code 44120 is not supported in the medical record. Based on the 
information provided, we decided that Medicare rules for coverage have not been met. Therefore, we decided 
that the Plan does not have to pay for the resection of the small intestine billed for services provided on 
December 27, 2019.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. 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. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the records do not show that 
skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve 
the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition 
and/or prevent deterioration. The records do not show that skilled therapy is needed to effectively provide 
treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a 
maintenance program to maintain the enrollee's level of function and/or prevent deterioration. As the enrollee 
does not require skilled therapy or skilled nursing services the enrollee does not meet the definition of home 
health aide services per Section 50.2 and the request for home health aide services are not reasonable and 
necessary to the treatment of the enrollee's illness or injury by the skilled professional staff. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Bydureon Bcise. 
 
You asked the Plan to pre-approve Bydureon Bcise. The Plan denied your request. The Plan says this drug is 
not covered for the enrollee's condition by Medicare Part B. 
 
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 Bydureon Bcise.  
 
Benefits for Bydureon Bcise 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets the criteria for an IRF admission. 
The Plan denied your request. The Plan says the documentation does not demonstrate a need for complex 
interdisciplinary therapy. The Plan also says that the enrollee's therapy needs can be met at a lower level of 
care. 
 
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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the enrollee does 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. Our physician reviewer also found that there is not a reasonable expectation that this enrollee 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with 
suspension sleeve (L1851, L2397) provided to the enrollee on May 14, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis 
(L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on May 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee from October 
30, 2018, through November 9, 2018. 
 
You asked the Plan to pay for the medical services. You say that the stay was medically necessary and you are 
requesting the Plan waive the timely filing and process the claims. The Plan denied your request. The Plan says 
the provider did not appeal the initial appeal; and when the provider submitted a correct claim it was also 
untimely. 
 
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 medical services was not filed until June 8, 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 medical services provided to the enrollee from October 30, 2018, through 
November 9, 2018.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Otezla. 
 
You asked the Plan to pre-approve Otezla. You say that the enrollee has tried and failed topical steroids. The 
Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by Part B. 
 
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 Otezla.  
 
Benefits for Otezla 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided from April 3, 2020, through 
April 28, 2020. 
 
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says the Plan 
requires 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 did not pre-approve the 
psychotherapy services. 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 psychotherapy services provided from April 3, 
2020, through April 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Spinal Cord Stimulator trial (63650). 
 
You asked the Plan to pre-approve Spinal Cord Stimulator trial. You say that the enrollee is not a surgical 
candidate and the doctor would like to trial a neurostimulator to use as an adjunctive therapy in the treatment of 
his radicular leg pain. The Plan denied your request. The Plan says the enrollee currently has a functioning 
implanted programmable pain pump. It would be a medical contraindication to have two programmable devices 
when one happens to be a pain pump. 
 
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 Spinal Cord Stimulator trial. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee does not have an evidence-based indication for a SCS.  He also 
has a functioning intra-thecal pump.  The NCD specifically states that another programmable device should not 
be implanted.  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 Spinal Cord Stimulator trial have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Spinal Cord Stimulator trial (63650).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on March 27, 2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one 
unit of CPT 81479 and the appropriate DEX Z-Code.  
 
We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT 
codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-
Code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on March 27, 
2020.