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

 
We decided that the Plan does not have to waive the copayment for the injection administered June 18, 2020, 
by the in-network outpatient department of the hospital. 
 
You asked the Plan to waive the copayment for the injection. You say that you were only in the office for two 
(2) minutes and you should not be charged $400 for a surgical procedure. The Plan denied your request. The 
Plan says the claim was processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received the injection on June 18, 2020, by the outpatient department of the 
in-network hospital. You are asked to pay a $400 copayment for the services. Your EOC states that enrollees 
must pay a S400 copayment per visit for outpatient surgery, including services provided at hospital outpatient 
facilities and ambulatory surgical centers. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the injection 
administered June 18, 2020, by the in-network outpatient department of the hospital.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the addition of tooth to an existing partial denture provided 
on February 12, 2020. 
 
You asked the Plan to pay for the addition of tooth to an existing partial denture. You say that you would like 
to know why these services were not paid. 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 
addition of tooth to an existing partial denture provided on February 12, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myrbetriq tablets. 
 
You asked the Plan to pre-approve Myrbetriq tablets. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Myrbetriq tablets are not covered under the enrollee's 
Medicare Part B 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 Myrbetriq tablets.  
 
Benefits for Myrbetriq 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee 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 enrollee does not 
have complex wound care or other ongoing SNF level SN need. The enrollee'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 enrollee 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 enrollee 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 admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee in this case is with chronic oxygen requirement at home who was admitted to the current acute care hospital with COVID-19 pneumonia and acute respiratory failure. He required mechanical ventilation, steroids, antibiotics, antivirals, antifungals, convalescent plasma, hemodialysis, and later underwent tracheostomy. He also recently underwent bilateral ureteral stent exchange which was planned prior to this admission. He as been improving and more stable lately with the ability to wean from mechanical ventilation. He does not have a stable feeding source at this time and is using an NG tube currently.The enrollee appears to be improving and more stable but still requires additional acute care services for the short term, particularlywhen nutrition and feeding status is more stable. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary 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-approvelong term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain. 
 
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 70450 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 70450 and 70496. Code 70450 is a column II code with a 
modifier indicator of 1 when billed with column I code 70496. Code 70450 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the 
computed tomography (CT) scan of the head/brain
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 27, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 
physician's 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 physician's services provided on February 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G orthosis. 
 
You asked the Plan to pre-approve the requested orthotic. You say that the MyoPro restores the most essential 
aspects of arm function. The Plan denied your request. The Plan says there is insufficient information to show 
this orthosis would be more effective than the traditional orthosis types that are covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested orthotic. Our physician 
reviewer found that the enrollee is now status post stroke in 2007, resulting in spastic hemiplegia affecting 
dominant right-side. His right upper extremity remains extremely weak. He is unable to weight bear throughout 
his wrist and hand with a 1-2 out of 5 strength. He requires total routine help for bimanual aspects of his 
activities of daily living. At this time the requested robotic orthosis is not proven to be more beneficial for 
treatment of the enrollees medical condition/function than any available standard therapy. The requested 
device is not reasonable and necessary for the diagnosis or treatment of the 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 the requested orthotic have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a MyoPro Motion G orthosis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on March 13, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician services. 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. The 
Plan says that the member's primary care physician did not refer these 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 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 physician services provided on March 13, 2020 by 
an out of network (OON) provider.
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 the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not 
medically necessary. 
 
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 admission to a LTACH is not medically necessary. Our physician reviewer found the 
enrollee in this case was admitted to the current acute care hospital with acute respiratory failure related to 
heart failure and fluid overload. She was treated with mechanical ventilation, oxygen, Levophed, and diuretics. 
The course was complicated by acute kidney injury, and septicemia, requiring milrinone and Entresto. She has 
been able to improve somewhat and initiate physical therapy recently. BNP is still elevated currently but 
improving. She requires ongoing milrinone drip for cardiorenal syndrome and a PICC line was placed for long-
term use of this medication. 
 
In this case, the enrollee appears to be improving and more stable but still requires additional acute care 
services for the short term. The enrollee does not require services at the LTACH that are not already available 
at the current facility. There are no services at the LTACH that are not already available and covered at the 
current facility. Therefore, this request for LTACH services will be considered not medically necessary 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: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pay fora CT scan (CPT 70450) provided to the enrollee on May 5, 2020.You asked the Planto pay forthe scan. You say that this should be paid for.The Plandenied your request. The Plansaysbased on the missing documentation, the original decision is being upheld, as the claim processed correctly.The Plan must followMedicare 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 70450 is "Computed tomography, head or brain; without contrast material."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 the scan. Our reviewer says that the scan at issue in this casewere not supported by the medical records. Our physician reviewer found billing both CPT 70450-26-59 and CPT 70496 with documentation supporting the modifier 59 (distinct procedural service) is considered unbundling; therefore, CPT 70450-26-59 would be not covered.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 scan have not been met.Therefore, we decided that the Plandoes not haveto pay fora CT scan (CPT 70450) provided to the enrollee on May 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Alcohol wipes, per box (A4245) provided March 25, 
2020. 
 
You asked the Plan to pay for the alcohol wipes. You say that the records should support the necessity of the 
service in dispute. The Plan denied your request. The Plan says there is no actual physical exam. All 
information was provided over the phone. The documentation does not identify the enrollee's originating site at 
the time of the telehealth visit. 
 
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 the Alcohol wipes, per box (A4245) provided 
March 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Low Dose Computed Tomography (LDCT) Lung 
Cancer Screening (G0297). 
 
You asked the Plan to pre-approve the LDCT Lung Cancer Screening. You say that the screening is medically 
necessary. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that in order to be covered for this screening, enrollees 
must have a 30 pack-year smoking history. 
 
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 LDCT Lung Cancer Screening. Our 
reviewer says that the LDCT Lung Cancer screening is not medically necessary. Our physician reviewer found 
that based on the medical records provided there is no documentation that meets the Medicare criteria for low 
dose computed tomography lung cancer screening. The records document a smoking history of one half pack 
per day for 45 years (22.5 pack-years); Medicare criteria require a 30 pack-year smoking history. 
 
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 LDCT Lung Cancer Screening have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Low Dose Computed Tomography (LDCT) Lung Cancer 
Screening (G0297).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CGM. 
 
You asked the Plan to pre-approve the CGM. You say that you would like reconsideration because this would 
help you to better understand what is going on with your sugar level. The Plan denied your request. The Plan 
says there is no clinical information to support the medical necessity of the CGM. 
 
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 CGM. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Medicare criteria call for 4 shots per day of insulin in order to cover a CGM. The record does 
not indicate that you use insulin or that a glucometer will not meet your needs. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a CGM.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided. 
 
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 a domiciliary or rest home visit provided.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve the Retacrit. You say that you would like reconsideration because this drug 
is medically necessary. The Plan denied your request. The Plan says this drug is not covered for your condition 
by Medicare Part B. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Retacrit.  
 
Benefits for the Retacrit 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe automatic external defibrillator (AED) rendered on February 28, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not billed correctly.The Plan must follow Medicare rules. The rules say that the -KJ modifier is for a DME item with capped rental months four to 15.We looked at the file and Medicare rules. The file shows that the provider billed procedure code K0606 with the -KJ modifier. Billing of months four to 15 is not appropriate for this item. 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 forthe automatic external defibrillator (AED) rendered on February 28, 2020.