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

We decided that the Plan does not have to pre-approve facet joint injections.
You asked the Plan to pre-approve facet joint injections. You say that you are appealing with medical records.
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because
neither clinical assessment nor Computed Tomography (CT) scan implicates the facet joint as the putative
source of the enrollee's pain.
The Plan follows Medicare rules. Medicare rules say that facet joint injections are only covered when the
enrollee meets certain specific coverage indications.
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 facet joint injections. Our reviewer says
that the enrollee does not meet the Medicare criteria for the requested facet joint injections. Our physician
reviewer found the enrollee has other probably sources of her lower back pain and also carries the diagnosis of
radiculopathy. This does not meet Medicare's coverage criteria and therefore the requested procedure is not
considered medically reasonable and 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 facet joint injections have not been met. Therefore, we decided that the Plan
does not have to pre-approve facet joint injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.
You asked the Plan to pre-approve a power wheelchair. The Plan denied your request. The Plan says that your
physician has not ordered this equipment for you.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The
rules state that DMEPOS is covered only when there is a physician order.
The file does not show that you have a mobility deficit that impairs your participation in MRADLs, your
condition cannot be improved by a walker, cane or manual wheelchair or that you can safely operate the PMD
being requested. This means that Medicare rules for coverage of a PMD have not been met. Your physician has
indicated he did not order a power wheelchair for you or sent in any medical records supporting the need for a
power wheelchair. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humira for the enrollee.
You asked the Plan to pre-approve this drug. 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 selfadministered
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 Humira 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided to the enrollee on
May 13, 2019.
You asked the Plan to pay for the orthosis. 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 wrist-hand orthosis
(L3916) provided to the enrollee on May 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a follow-up visit provided on November 6, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for a follow-up visit. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained.
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 a follow-up visit provided on November 6, 2019
by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound debridement provided on September 17, 2019, October 1, 2019 and October 22, 2019.
You asked the Plan to waive the copayment for wound debridement. You say that no surgery was performed. You say that the bill should be waived. The Plan denied your request. The Plan says the copayments applied 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). Your contract with the Plan clearly says that you must pay a $400 copayment for in-network, Medicare-covered outpatient hospital surgery services. You have been asked to pay a total of $722.67 for wound debridement.
Date of Service
Service
Allowed Amount
Standard Copayment
Member Liability
September 17, 2019
Wound Debridement
$191.18
$400
$191.18
October 1, 2019
Wound Debridement
$191.18
$400
$191.18
October 22, 2019
Wound Debridement
$340.31
$400
$340.31
TOTAL:
$722.67
Wound debridement falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. Wound debridement is considered a surgical procedure. 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 wound debridement provided on September 17, 2019, October 1, 2019 and October 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on October 23, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you were scheduled for a wellness visit but also received an injection. You say they did not bill for the scheduled wellness visit and instead charged a copayment for an office visit. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $10 copayment for each covered visit or consultation in an outpatient location with your PCP or other primary care physician. You have been asked to pay a $10 copayment for the office visit. The office visit falls within the "Physician/
Practitioner services, including doctor's office visits" benefit category. The medical record shows you were seen for a six-month follow-up.
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 office visit provided on October 23, 2019.
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 is a high risk for falls, and not safe to be
sent directly home. The Plan denied your request. The Plan says the enrollee does not have complex medical
conditions which require physician supervision and an intensive team for 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 physician reviewer found
that you are generally medically stable with multiple sclerosis, with new onset weakness. There is no evidence
of complex medical issues that require monitoring by an inpatient rehab physician three times per week, or
need for acute rehab nursing care. While you may benefit from continuing physical and occupational therapy,
there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent
physician oversight and an interdisciplinary approach to rehabilitation 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda in combination with Yervoy for the enrollee.
You asked the Plan to pre-approve the requested drugs. You say that the enrollee developed rashes to Opdivo. The Plan denied your request. The Plan says studies have not proven this combination of drugs is helpful for the enrollee's diagnosis.
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 requested drugs. Our physician reviewer found that the enrollee has metastatic renal cell cancer. There is no compendia or literature to support Keytruda in combination with Yervoy. Therefore, the requested drug is not considered medically reasonable and 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 requested drugs have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda in combination with Yervoy for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for a knee x-ray with 3 views (CPT 73562-26) and knee x-ray with 1-2
views (CPT 73560-26) billed for date of service July 22, 2019.
You asked the Plan to pay for CPT codes 73562-26 and 73560-26. You say that the enrollee had multiple
exams on this date of service. You say that the attached records support the level of service and the claim
should be reprocessed for payment. The Plan denied your request. The Plan says that the services in dispute
were billed with the wrong modifier. The Plan says that the provider billed with a modifier of 77 instead of 76.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment. The rules also say that the denial of a claim as a duplicate of another claim may be appealed when the
denial is based on criteria other than those specified for exact duplication.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Specifically, the plan has not supported their argument that the charges in
dispute were a duplicate to a previously paid claim. The records supplied show that the services in dispute were
provided by the billing provider on the date of service. Therefore, we decided that the Plan has to pay for a
knee x-ray with 3 views (CPT 73562-26) and knee x-ray with 1-2 views (CPT 73560-26) billed for date of
service July 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider from March 22, 2019, to September 27, 2019.
You asked the Plan to pay for the services. You say that you did not know this provider was not in-network. 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 you by an out-of-network provider from March 22, 2019, to September 27, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from August 17, 2019 through August 20, 2019.
You asked the Plan to waive the copayment for the inpatient stay. You say that you cannot afford the bill. You say that you are not responsible for the bill. The Plan denied your request. The Plan says the copayment applied 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). Your contract with the Plan clearly says that you must pay a $285 copayment per day, for days 1-6 per stay. You have been asked to pay an $855 copayment for the inpatient stay. ($285/day x 3 days = $855). The inpatient stay 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 copayment for the inpatient stay provided from August 17, 2019 through August 20, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission for the enrollee.

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 admission 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital with shortness of breath. He received oral and inhaled medications and insulin. He had stable vital signs and was treated with oxygen and BiPAP. He received physical therapy in the hospital and needs supervision for functional mobility, including gait to 30 feet with no assistive device. He has no skilled nursing or skilled therapy needs. He does not require skilled nursing or skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF level of 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided from January 23,
2019 to May 13, 2019.
You asked the Plan to pay for home infusion therapy. You say that this was a medically necessary service. The
Plan denied your request. The Plan says this code is not valid for Medicare purposes.
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 CPT code S9328 is not supported in the medical record. Specifically, this code has a status
indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this
information, we decided that Medicare rules for coverage of home infusion therapy have not been met.
Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided from
January 23, 2019 to May 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tramadol extended release tablets.
You asked the Plan to pre-approve self-administered drugs. You say that the enrollee is currently out of medication and changing medication would be detrimental to the enrollee's health. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not cover the enrollee's Medicare Part D prescription drug benefits.
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 Tramadol extended release tablets.
Benefits for self-administered drugs 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 pay for surgical assistant services on the drainage of an abscess (10061) provided on August 16, 2019.
You asked the Plan to pay for surgical assistant services. You say that surgical assistant services were medically necessary. The Plan denied your request. The Plan says surgical assistant services are not covered for this procedure.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 10061. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for surgical assistant services have not been met. Therefore, we decided that the Plan does not have to pay for surgical assistant services on the drainage of an abscess (10061) provided on August 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the massage therapy services you received on July 18, 2019.
You asked the Plan to pay for the services. You say that you asked the plan to receive these benefits. The Plan
denied your request. The Plan says you did not have alternative medicine benefits at the time the services were
rendered.
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. The records
show that you did not request to change your supplemental benefit to alternative medicine until after the
massage therapy services were received. This means that you did not have an active supplemental benefit that
would cover massage therapy for the date of service in question. Therefore, we decided that the Plan does not
have to pay for the massage therapy services you received on July 18, 2019.
Appeal type: Lab
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 September 27, 2019.
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 September 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on January 21, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 95999 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 95999 is unlisted neurological or neuromuscular
diagnostic procedure.
We find that CPT code 95999 is not supported in the medical record. Specifically, the records show that Train
of Four testing was performed and there is a more specific code for these services. Based on this information,
we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that
the Plan does not have to pay for the services rendered to the enrollee on January 21, 2019.