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

 
We decided that the Plan does not have to pay for practitioner services provided to the enrollee on August 17, 
2020, and billed under code 99601. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says CPT code 99601 is assigned a status code I  defined as "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. In this case, this claim was submitted with a 
code not paid by Medicare in this setting. Medicare rules for coverage of this service have not been met. 
Therefore, we decided that the Plan does not have to pay for practitioner services provided to the enrollee on 
August 17, 2020, and billed under code 99601.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye exam (92014) received from an out of network 
provider on July 20, 2020. 
 
You asked the Plan to pay for an eye exam. You say that a representative of the Plan told you services would 
be covered with 20% coinsurance. The Plan denied your request. The Plan says rules for payment have not 
been met. 
 
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 Plan covers eye exams when received from an in-network provider. 
 
We looked at the file and the Plan's rules. We noted that you received an eye exam from an out of network 
provider. Based on this information, we decided that the Plan's rules for coverage of an eye exam have not been 
met. Therefore, we decided that the Plan does not have to pay for an eye exam (92014) received from an out of 
network provider on July 20, 2020.  
 
Your complaint about receiving erroneous or misleading information about your benefits from a representative 
of the Plan 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: 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. The Plan denied your request. The Plan says the enrollee does not 
require a comprehensive rehab program. 
 
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 were admitted to the acute hospital for surgical repair of a hip fracture after a fall. Your medical 
conditions are stable. The complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record 
documents a need for physical and occupational therapy, it does not document a need for an intensive 
rehabilitation program. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services with CPT codes 63015, 22853, and 
20939 provided on February 14, 2020. 
 
You asked the Plan to pay for CPT codes 63015, 22853, and 20939. You say that the medical records support 
the billing of CPT codes 63015, 22853, and 20939 provided on February 14, 2020. The Plan denied your 
request. The Plan says the medical records do not support the billing of CPT codes 63015, 22853, and 20939 
provided on February 14, 2020. 
 
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 63015 is Laminectomy with exploration and/or 
decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, 
spinal stenosis), more than 2 vertebral segments; cervical. The CPT Code Manual definition of code 22853 is 
Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation 
for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with 
 
 
interbody arthrodesis, each interspace (List separately in addition to code for primary procedure). The CPT 
Code Manual definition of code 20939 is Bone marrow aspiration for bone grafting, spine surgery only, 
through separate skin or fascial incision (List separately in addition to code for primary procedure). 
 
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 CPT codes 63015, 22853, and 20939. Our 
reviewer says that the medical records do not support the billing of CPT codes 63015, 22853, and 20939 
provided on February 14, 2020. Our physician reviewer found the documentation submitted was reviewed, and 
does not meet criteria.  Documentation submitted includes office visit notes for dates of service: December 18, 
2019, November 20, 2019, November 13, 2019 and November 7, 2019.  Documentation did not include an 
operative report to review. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CPT codes 63015, 22853, and 20939 have not been met. Therefore, we decided 
that the Plan does not have to pay for the surgical services with CPT codes 63015, 22853, and 20939 provided 
on February 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgical services provided 
August 6, 2020. 
 
You asked the Plan to waive the copayment for the outpatient services. You say that it is not your fault the 
doctor didn't get everything in the first surgery and you should not have to pay for the second surgery. The Plan 
denied your request. The Plan says the claim was processed and the correct copayment was applied per the plan 
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). Your contract with the Plan clearly says that you must pay $350 
copayment for outpatient hospital facility services.  
 
You have been asked to pay $350 copayment for outpatient hospital services. The outpatient hospital services 
fall within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers 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 outpatient surgical 
services provided August 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that you need a post-surgery follow up visit. The 
Plan denied your request. The Plan says the enrollee's condition is stable and can be safely treated by a network 
provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue. We found no exception that would require the Plan to pre-
approve these OON services. Therefore, we decided that the Plan does not have to pre-approve medical 
services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the care can be received in another setting, such as a skilled nursing facility, or home 
with home health services. 
 
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 enrollee 
was admitted for shortness of breath and back pain. 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. The 
recommendation of the occupational therapist is for skilled nursing placement. There is not a reasonable 
expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the requested epidural steroid 
injection is medically necessary. The Plan denied your request. The Plan says the requested epidural steroid 
injection 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 an epidural steroid injection. Our 
reviewer says that the requested epidural steroid injection is not medically necessary. Our physician reviewer 
found the enrollee is with a 5 month history of worsening thoracic and chest wall pain after accidentally being 
pushed. She has been diagnosed with thoracic degenerative disease and thoracic disc condition with 
radiculopathy. 
 
In this case, the documentation indicates that the enrollee had a thoracic ESI performed on 11/10/2020. The 
documentation in the office note dated 11/30/2020 stated that the member did not find any significant pain 
relief with the first injection. There is no clinical rationale for the requested second thoracic ESI. 
 
The review has determined that the requested epidural steroid injection is not medically reasonable and 
necessary for the enrollee 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 an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 home health skilled nursing visits (G0299) and 13 
hours per week of home health aide services (G0156). 
 
 
 
You asked the Plan to pre-approve home health skilled nursing visits and home health aide services. You say 
that you need home health care services. The Plan denied your request. The Plan says the rules for home health 
care services have not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health skilled nursing visits and 
home health aide services. Our reviewer says that the services requested are not medically necessary. Our 
physician reviewer found no medical records signed by a physician have been provided documenting a skilled 
nursing need and thus home health aide services are 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 home health skilled nursing visits and home health aide services have not been 
met. Therefore, we decided that the Plan does not have to pre-approve 9 home health skilled nursing visits 
(G0299) and 13 hours per week of home health aide services (G0156).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha SureClick. 
 
You asked the Plan to pre-approve Repatha SureClick. You say that this treatment is medically necessary. The 
Plan denied your request. The Plan says rules for pre-approval have not been met. 
 
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 Repatha SureClick.  
 
Benefits for Repatha SureClick 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal services (D4999) provided on July 28, 2020. 
 
You asked the Plan to pay for periodontal services. You say that these services were necessary. The Plan 
denied your request. The Plan says these services are 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 
periodontal services (D4999) provided on July 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided to the enrollee on 
February 14, 2020. 
 
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 services are not supported by the records. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the orthosis have not been met. The medical records sent in with 
the appeal are dated several months prior to the order of the back brace. The records for date of service 
September 17, 2019, identifies the services as a follow up after being last seen June 25, 2019, for back pain 
associated with previous lumbar surgery. There is no mention in the records or in the Plan section of the 
records for the need of a back brace. Therefore, we decided that the Plan does not have to pay for lumbar-sacral 
orthosis (L0650) provided to the enrollee on February 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the core buildup (D2950) and endodontic therapy 
(D3330). 
 
You asked the Plan to pre-approve the core buildup and endodontic therapy. You say that the services 
requested are medically necessary. The Plan denied your request. The Plan says these dental services are not 
covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 pre-approve the 
core buildup (D2950) and endodontic therapy (D3330).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound of extra cranial arteries 
(93880) performed. 
 
You asked the Plan to waive the copayment for an ultrasound of extra cranial arteries. You say that the Plan 
should only make one payment for the services you received. The Plan denied your request. The Plan says the 
correct copayment was applied. 
 
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 $50 
copayment for lab services at an outpatient hospital.  
 
You have been asked to pay a $50 copayment for an ultrasound of extra cranial arteries. An ultrasound of 
extracranial arteries performed at an outpatient hospital falls within the "Outpatient hospital services" 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 an ultrasound of extra cranial arteries (93880) 
performed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from September 6, 2020, 
through September 7, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The 
Plan denied your request. The Plan says the stay was not medically necessary. The Plan must follow Medicare 
rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital 
care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient 
hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not 
support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has 
determined that the record did not show that at the time of inpatient admission the admitting physician 
reasonably expected that your necessary hospital care (including earlier emergency department (ED) and/or 
observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. 
Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have 
not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided 
from September 6, 2020, through September 7, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a thoracic lumbar sacral orthosis (TLSO) provided on July 16, 2020. 
 
You asked the Plan to pay for TLSO. You say that no patient should be denied care or pain management 
solutions because they are required to have historical documentation. The Plan denied your request. The Plan 
says that the denial of payment for this item is correct, because without a face-to-face encounter the ordering 
physician could not gather the information associated with diagnosis, treating, or managing the clinical 
condition for which the DMEPOS item was ordered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare may select certain items to require a 
face-to-face encounter for coverage. TLSO with code L0457 is not among those items which have been 
selected for face-to-face encounter requirements. 
 
We looked at the file and Medicare rules. The Plan has denied payment for this item on the basis that it did not 
meet face-to-face encounter requirements. However, L0457 is not among those items which have been selected 
to require a face-to-face encounter. The documentation submitted does include a standard written order, 
medical records, correct coding, and proof of delivery, which fulfill the documentation requirements for L0457. 
 
 
Based on this information, we decided that Medicare rules for coverage of TLSO have been met. Therefore, we 
decided that the Plan has to pay for a thoracic lumbar sacral orthosis (TLSO) provided on July 16, 2020.  
 
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.