Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for parenteral nutrition solution, per 10 grams lipids (B4185) 
parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes (B4197) parenteral 
supply kit (B4222) and parenteral nutrition administration kit (B4224). 
 
You asked the Plan to pay for the parenteral nutrition supplies. You say that these codes were paid on multiple 
claims for this enrollee with the same documentation. You request review of all medical records and reprocess 
this claim for correct payment. The Plan denied your request. The Plan says the records do not support the 
service billed. 
 
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. The records do not 
include a signed delivery sheet of when billed supplies was received. 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 parenteral nutrition solution, per 10 grams lipids (B4185) parenteral nutrition solution; 
compounded amino acid and carbohydrates with electrolytes (B4197) parenteral supply kit (B4222) and 
parenteral nutrition administration kit (B4224).
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan does not have to pre-approve nineteen additional physical therapy visits for the 
enrollee. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says the plan can only approve 10 of the 29 visits. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the requested additional therapy beyond what was approved by the 
health plan is not generally accepted as specific and effective therapy for the enrollee's condition beyond what 
was approved by the health plan. The enrollee has had prior therapy for this condition, and it does not appear 
that the enrollee's functional level requires the unique skills of a professional therapist to safely and effectively 
provide treatment, that the services can be safely and effectively performed only by a therapist, or under the 
supervision of a therapist. The enrollee has been authorized additional sessions which would have been 
sufficient to review a an independent exercise program and ensure safety. The ongoing specialized skill, 
knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to 
maintain the enrollee's current condition or to prevent or slow further deterioration. 
 
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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve nineteen additional physical therapy visits for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection procedure into sacroiliac joint (27096) provided 
on March 12, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the injection procedure into sacroiliac joint. 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 injection procedure into sacroiliac joint 
(27096) provided on March 12, 2020, by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pembrolizumab injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested treatment is not in the order recommended by the NCCN. 
 
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 injection. Our reviewer says that the 
requested injection is not medically reasonable or necessary. Our physician reviewer found Pembrolizumab is 
FDA approved as single agent therapy in patients with metastatic NSCLC, and with tumors with PD-L1 
expression (tumor proportion score [TPS] 1% or more), as determined by an approved test, and with no 
epidermal growth factor receptor (EGFR) or anaplastic lymphoma kinase (ALK) genomic tumor aberrations. 
The enrollee has not yet had any molecular testing. The service is 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Pembrolizumab injection for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on June 17, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. 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. 
 
We find that the Guardant360 testing is not supported in the medical record. Specifically, this service required 
the use of code 81479. In addition, the appropriate DEX Z Code identifier should be entered adjacent to the 
code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of 
the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on June 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assisted living visit with removal of tissue and removal of 
skin growth (99335, 99336, 11056, 11721) provided on July 2, 2020, to July 8, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for the assisted living visit with removal of tissue and removal of skin growth. You 
say that the services provided were medically necessary. 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 assisted living visit with removal of tissue and 
removal of skin growth (99335, 99336, 11056, 11721) provided on July 2, 2020, to July 8, 2020 by an out of 
network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a low dose CT scan provided on August 4, 
2020. 
 
You asked the Plan to waive the copayment for a low dose CT scan. You say that you were not charged for a 
previous CT scan and were told you would not owe a copayment. The Plan denied your request. The Plan says 
the claims were processed correctly and you are being charged the correct 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 $150 
copayment for CT scans.  
 
The record shows that you had a previous low dose CT scan on February 4, 2020. A low dose CT scan is only 
covered once every 12 months. Therefore, you are responsible to pay the $150 copayment for a low dose CT 
scan provided on August 4, 2020.  
 
You have been asked to pay a $150 copayment for a low dose CT scan. A low dose CT scan falls within the 
outpatient diagnostic tests and therapeutic services and supplies 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 a low dose CT scan provided on August 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for vision care and a Medicare Part B drug 
provided on May 30, 2018. 
 
You asked the Plan to waive the copayments for vision care and a Medicare Part B drug. You say that you 
disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and 
you are being charged the correct 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 $40 
copayment for vision care. Your contract with the Plan also clearly says that you must pay a $50 copayment for 
Medicare Part B prescription drugs.  
 
You received vision care on May 30, 2018. Therefore, you are responsible to pay the $40 copayment.  
 
You received a Medicare Part B drug on May 30, 2018. Therefore, you are responsible to pay the $50 
copayment.  
 
The total amount you owe is: $90.  
 
You have been asked to pay the total copayments amount of $90 for vision care and a Medicare Part B drug. 
Vision care falls within the vision care benefit category. A Medicare Part B drug falls within the Medicare Part 
B prescription drugs 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 vision care and a 
Medicare Part B drug provided on May 30, 2018.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the patient does not require skilled nursing 
services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely 
and effectively provide medically necessary and reasonable treatment in a SNF. The patient does not have 
complex wound care or other ongoing SNF level SN need. The patient's functional level does not require 
skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely 
and effectively provide medically necessary and reasonable treatment in a SNF. The patient does not require 
skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a 
practical matter, this patient does not require the necessary services on an inpatient basis, in a skilled nursing 
facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided there is 
no documentation that you require skilled nursing services, i.e., the specialized skill, knowledge and judgment 
of a skilled professional nurse is not required to safely and effectively provide medically necessary and 
reasonable treatment. You do not require skilled therapy services, i.e., the specialized skill, knowledge and 
judgment of a qualified therapist is not required to safely and effectively provide medically necessary and 
reasonable treatment. Daily skilled services are not required. You do not require the services on an inpatient 
basis, in a skilled nursing facility setting.  Services in a long-term care facility on a part time basis appear 
appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for inpatient hospital care provided from June 
25, 2020, to June 28, 2020. 
 
You asked the Plan to waive the coinsurance for inpatient hospital care. You say that you disagree with the 
charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct 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 10% 
coinsurance for inpatient hospital care.  
 
You received inpatient hospital care from June 25, 2020, to June 28, 2020. The total allowed amount is 
$14,019.95 and 10% of that is $1,402.00.  
 
You have been asked to pay the total coinsurance amount of $1,402.00 for inpatient hospital care. Inpatient 
hospital care falls within the inpatient hospital 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 
coinsurance for inpatient hospital care provided from June 25, 2020, to June 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services (A0429) received 
on May 11, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. The Plan denied your request. The 
Plan says you were charged this cost sharing correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $265 copayment per date of service. The enrollee had 1 ambulance trip on May 11, 2020. The Plan 
charged the enrollee $265 for these services. This means that the enrollee has been asked to pay the correct 
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to 
pay when enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
the ambulance services (A0429) received on May 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960 ) provided on 
June 3, 2020. 
 
You asked the Plan to pay for the shoulder elbow wrist hand orthosis. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted 
records do not support the need or justification for the brace. 
 
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 relevant medical records which support medical necessity for the supplies provided 
in this case. 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 shoulder elbow wrist hand 
orthosis (L3960 ) provided on June 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trijardy XR for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. 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 Trijardy XR 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test (80307, G0480) provided on July 9, 2020, by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the drug test. You say that the services provided were medically necessary and 
you were unaware a prior authorization was needed. 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 drug test (80307, G0480) provided on July 9, 
2020, by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the implant body placement and extractions provided on 
February 28, 2020. 
 
You asked the Plan to pay for the implant body placement and extractions. You say that you suffered bone 
deterioration from existing implants. You say that you were pre-approved for every treatment listed. The Plan 
denied your request. The Plan says out-of-network dental services are not covered 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, out-of-network dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
implant body placement and extractions provided on February 28, 2020.  
 
Your complaint about inhumane treatment 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination, knee (73564) provided on May 19, 
2020. 
 
You asked the Plan to pay for the knee x-ray. You say that please see the attached report showing this code was 
provided by your radiologist for the care and treatment of the enrollee. Review and adjust for payment.  The 
Plan denied your request. The Plan says the diagnosis code associated to it are mismatched to the procedure 
modifier on the claim line. 
 
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 73564 is radiologic examination, knee. 
 
We find that CPT code 73564 is not supported in the medical record. Specifically, it is not appropriate to report 
unspecified, left, right or bilateral diagnosis codes when the procedure modifier on the claim line does not 
match the diagnosis code. Based on this information, we decided that Medicare rules for coverage of the knee 
x-ray have not been met. Therefore, we decided that the Plan does not have to pay for radiologic examination, 
knee (73564) provided on May 19, 2020.