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

 
We decided that the Plan does not have to pay for the subsequent nursing facility care services provided on 
January 31, 2019. 
 
You asked the Plan to pay for the subsequent nursing facility care services. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the claim was not filed timely. 
 
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 subsequent nursing facility care services was not filed until October 16, 
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 subsequent nursing facility care services 
provided on January 31, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a patency capsule test. 
 
You asked the Plan to pre-approve the patency capsule test. You say that you do not agree with the denial 
rationale. The Plan denied your request. The Plan says this testing cannot be covered per Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that patency capsule testing is not covered due to lack 
of sufficient peer-reviewed literature supporting its use. Therefore, we decided that the Plan does not have to 
pre-approve a patency capsule test.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for CT scans provided on June 22, 2020, and 
August 25, 2020. 
 
You asked the Plan to waive the copayment for CT scans. You say that you are the only one paying anything 
toward 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 $200 
copayment per visit for CT scans. 
 
You received a CT scan on June 22, 2020. Therefore, you are responsible to pay the allowed amount of 
$110.54, which is less than the $200 copayment.   
 
You received a CT scan on August 25, 2020. Therefore, you are responsible to pay the allowed amount of 
$150.78, which is less than the $200 copayment.   
 
The total amount you owe is: $261.32. 
 
You have been asked to pay the total copayment amount of $261.32 for CT scans. CT scans fall 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 CT scans provided on June 22, 2020, and August 25, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve a combination of Pemetrexed Injection, pemetrexed, 10 mg 
(J9305) and Carboplatin Injection, carboplatin, 50 mg (J9045). 
 
You asked the Plan to pre-approve the combination of Pemetrexed injection and Carboplatin injection. You say 
that you want the enrollee treated with this drug combination. The Plan denied your request. The Plan says that 
the off-label use of this drug is not medically accepted per Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the combination of Pemetrexed 
injection and Carboplatin injection. Our reviewer says that the drug combination meets criteria. Our physician 
reviewer found the use supported by clinical research that appears in a CMS-approved medical journal. The use 
is not listed as not indicated, not supported or not recommended in any of the compendia. The documentation 
supports that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 combination of Pemetrexed injection and Carboplatin injection have been 
met. Therefore, we decided that the Plan has to pre-approve a combination of Pemetrexed Injection, 
pemetrexed, 10 mg (J9305) and Carboplatin Injection, carboplatin, 50 mg (J9045).  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 5, 2019. 
 
You asked the Plan to pay for the services provided. You say that you depend on the facility for timely 
notification of the enrollee's health insurance coverage. The Plan denied your request. The Plan says the claim 
was received past the allowed timeframe. 
 
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 services provided was not filed until August 28, 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 on June 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature. 
 
You asked the Plan to pre-approve the requested item. The Plan denied your request. The Plan says the item is 
non-covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation feature.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam with photos (92250) and contact lens fitting 
(92310) provided on February 24, 2020. 
 
You asked the Plan to pay for the eye exam with photos and contact lens fitting. You say that you believed you 
did not need prior authorization. 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 generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 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. Based 
on this information, we decided that the Plan's rules for coverage of the eye exam with photos and contact lens 
fitting have not been met. Therefore, we decided that the Plan does not have to pay for the eye exam with 
photos (92250) and contact lens fitting (92310) provided on February 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the spacer is experimental, and more research is needed to show safety and efficacy. There is no spinal 
instability. The hardware is not needed. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
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 16, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no clinical advantage of the inpatient rehab facility over the acute hospital.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs did not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status 
currently does not require intensive physician and nursing supervision in an IRF. While you may benefit from 
additional physical and occupational therapy the documentation does not support that you require or support 
that you will fully participate in this therapy on an IRF level. 
 
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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided 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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient does require physical therapy and 
occupational therapy services but based on the medical records provided the patient does not require an 
intensive inpatient rehabilitation therapy program. There is concern that the patient will not be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility due to the pace of his progress with therapy. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0482) provided on September 4, 2020. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were not emergent. There were network providers available. 
 
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 service 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 lab services (G0482) provided on September 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre 14 Day Reader (CPT Codes: K0553 and 
K0554). 
 
You asked the Plan to pre-approve the diabetic supplies. You say that the diabetic supplies are necessary. The 
Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the diabetic supplies. Our physician 
reviewer found the review has determined that the medical records provided do not meet the requirements 
listed in the LCD for Medicare coverage. 
 
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 diabetic supplies have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Freestyle Libre 14 Day Reader (CPT Codes: K0553 and K0554).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's medical management and rehab needs 
require an inpatient rehab stay and close physician supervision. You say that an IRF is both physically and 
medically necessary for the enrollee to return home at her maximum level of functioning with a decreased risk 
for readmission. The Plan denied your request. The Plan says the guidelines for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for surgical repair of a hip fracture after a fall.  
 
The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There 
are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record documents a need for physical and occupational therapy, it does not document a need 
for an intensive rehabilitation program. There is not a reasonable expectation that the 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of residual tooth rots (D7250), incision and 
drainage of abscess (D7511), and deep sedation/general anesthesia (D9222, D9223) provided on September 8, 
2020. 
 
You asked the Plan to pay for the removal of residual tooth rots, incision and drainage of abscess, and deep 
sedation/general anesthesia. You say that you believed you were covered for the services provided. The Plan 
denied your request. The Plan says the services provided are not a covered benefit under your dental plan. 
 
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 
removal of residual tooth rots (D7250), incision and drainage of abscess (D7511), and deep sedation/general 
anesthesia (D9222, D9223) provided on September 8, 2020.  
 
Your complaint about potentially receiving misinformation regarding your coverage is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transpedicular approach with decompression of spinal 
cord with CPT code 63056 and laminotomy with decompression of nerve root with CPT code 63030-51 
provided on August 4, 2020. 
 
You asked the Plan to pay for CPT codes 63056 and 63030-51. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
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, we have confirmed that code CPT 
code 63056 has a bundled relationship with code 63030 and cannot be paid as billed. This code cannot be paid 
as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. 
 
Furthermore, CPT code 63030-51 cannot be paid as billed, as the file shows the Plan paid for this service on a 
previous claim. Therefore, we decided that the Plan does not have to pay for the transpedicular approach with 
decompression of spinal cord with CPT code 63056 and laminotomy with decompression of nerve root with 
CPT code 63030-51 provided on August 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar spine fusion. 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary and 
beneficial to the enrollee's health. The Plan denied your request. The Plan says they do not see that the enrollee 
has: failed non-surgical treatment for a period of time (shots/physical therapy for six weeks or longer), major 
new problems with strength, bone loss problems in the enrollee's spine (osteomalacia), or problems with 
surgery they had before. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the criteria for spine surgery not met. There is no documentation of an adequate trial and failure 
of conservative measures to include physical therapy (PT). More conservative measures are needed. There are 
no red flags for surgery 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar spine fusion.