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

We decided that the Plan does not have to pre-approve a spinal cord stimulator for the enrollee. 
 
You asked the Plan to pre-approve the stimulator. You say that the records support this request. The Plan 
denied your request. The Plan says this procedure is not recommended until further psychiatric testing has been 
completed. 
 
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 stimulator. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee does not have an evidence-based indication for a SCS trial. The enrollee does not 
have psychological clearance for this trial. The requested procedure is not medically reasonable or 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 stimulator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a spinal cord stimulator for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on October 9, 
2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges 
because the doctor did not do anything. 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 $50 
copayment for each specialist office visit.  
 
You have been asked to pay a $50 copayment for a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctor?s office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a specialist visit provided on October 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device for the 
enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of the Vertiflex Superion 
Interspinous device in the setting of lumbar stenosis and neurogenic claudication has not been demonstrated in 
the peer-reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The spacer is 
experimental. More research is needed to show safety and efficacy of the device. Our physician reviewer found 
that the enrollee's condition does not meet criteria for these services. 
 
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 the Vertiflex Superion Interspinous device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lead wires provided on September 22, 2020. 
 
You asked the Plan to pay for lead wires (A4557). You say that the Plan should pay this claim. The Plan denied 
your request. The Plan says a TENS device was purchased in the previous twelve months therefore the lead 
wires have been denied. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
The record shows a TENS device was purchased on July 22, 2020, and records supporting the medical 
necessity of the additional lead wires were not submitted. Therefore, we decided that the Plan does not have to 
pay for lead wires provided on September 22, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on January 24, 
2020. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you only owed a $40 copayment in 
the past and disagree with the charges. The Plan denied your request. The Plan says the claims were processed 
correctly, and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 
copayment for allergy testing and a $100 copayment for all other diagnostic tests.  
 
You have been asked to pay a $100 copayment for an ultrasound. An ultrasound falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for an ultrasound provided on January 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 29, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the 
laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation 
and/or claim history indicates that the specimen was obtained in an office setting POS 11. 
 
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare 
Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting 
where the beneficiary receives the face to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, the claim was submitted with a laboratory 
place of service code while the record indicates that the face-to-face services were rendered in an office setting. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on April 29, 
2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the coinsurance for the 
esophagogastroduodenoscopy (43249) and biopsy (43239) procedures provided on December 20, 2019. 
 
You asked the Plan to waive or reduce the coinsurance for these surgical procedures. You say that you received 
multiple bills for the same procedures. The Plan denied your request. The Plan says that the initial bill had the 
wrong allowed amounts applied. This information was corrected in a subsequent bill, and the coinsurance was 
updated to reflect 25% on the new cost. 
 
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 25% 
coinsurance for each surgical or observation room service you get at an outpatient hospital.  
 
You have been asked to pay $357.75, which is 25% coinsurance for these surgical procedures. The Plan 
allowed amount for both services is $1,431.01 ($1,431.01 x 25% = $357.75). These services are surgical or 
observation room services provided at an outpatient hospital facility. 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 or 
reduce the coinsurance for the esophagogastroduodenoscopy (43249) and biopsy (43239) procedures provided 
on December 20, 2019.  
 
Your complaint about what you may currently owe for this service and receiving multiple bills due to changes 
or corrections to the Plan's allowed amounts 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on September 15, 
2020. 
 
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 
domiciliary or rest home visit. 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 on 
September 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for determination of refractive state (92015) and prescription of 
optical and physical characteristics of and fitting of contact lens (92310) provided on July 10, 2020. 
 
You asked the Plan to pay for determination of refractive state and prescription of optical and physical 
characteristics of and fitting of contact lens. You say that the services should be covered. The Plan denied your 
request. The Plan says the routine vision services were correctly denied as not covered under the medical plan. 
 
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 these services when The Plan covers services listed in the Plan?s benefit chart, 
however, claims must be filed to Vision Service Plan.. 
 
We looked at the file and the Plan's rules. Claims must be filed to the Vision Service Plan. Based on this 
information, we decided that the Plan's rules for coverage of determination of refractive state and prescription 
of optical and physical characteristics of and fitting of contact lens have not been met. Specifically, the claim 
was submitted to the incorrect Plan. Therefore, we decided that the Plan does not have to pay for determination 
of refractive state (92015) and prescription of optical and physical characteristics of and fitting of contact lens 
(92310) provided on July 10, 2020.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do 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 you 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Yescarta treatments. 
 
You asked the Plan to pre-approve the Yescarta treatments. You say that the requested treatment is medically 
indicated. The Plan denied your request. The Plan says the enrollee failed a similar medication, Kymriah. Use 
of Yescarta is not indicated at this time. 
 
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 Yescarta treatments. Our reviewer 
says that the requested treatment is not considered reasonable and necessary in this case. Our physician 
reviewer found the enrollee has transformed follicular lymphoma to high grade lymphoma. The enrollee has 
undergone many treatments, including Kymriah in 2019. As the patient has already failed a previous chimeric 
antigen receptor treatment (CART), the use of this drug is not supported. 
 
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 Yescarta treatments have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Yescarta treatments.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from August 
27, 2020, to September 10, 2020. 
 
You asked the Plan to pay for the SNF care. You say that the SNF care was medically necessary. The Plan 
denied your request. The Plan says rules for SNF care have not been met. 
 
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 pay for the SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service 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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided from August 27, 2020, to September 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on June 16, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because this 
testing is medically necessary and a covered benefit. The Plan denied your request. The Plan says the submitted 
claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted 
medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 
11. 
 
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare 
Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting 
where the beneficiary receives the face to-face service.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, the claim was submitted with a laboratory 
place of service code but the record indicates that the face-to-face service was rendered in an office setting. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on June 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electroencephalogram (EEG) extended monitoring 
services coded 95813 and the short-latency somatosensory evoked potential study services coded 95938 
provided on March 11, 2020. 
 
You asked the Plan to pay for the electroencephalogram (EEG) extended monitoring services and the short-
latency somatosensory evoked potential study services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 codes 95813 and 95938 are not supported in the medical record. Specifically, these services 
were billed with place of service 15 (Mobile Unit). This billed place of service is not supported by the 
documentation. The documentation shows that the enrollee was inpatient at the time services were provided. 
Based on this information, we decided that Medicare rules for coverage of the electroencephalogram (EEG) 
extended monitoring services and the short-latency somatosensory evoked potential study services have not 
been met. Therefore, we decided that the Plan does not have to pay for the electroencephalogram (EEG) 
extended monitoring services coded 95813 and the short-latency somatosensory evoked potential study 
services coded 95938 provided on March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) trial. 
 
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 services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an SCS trial is covered when specific criteria are 
met. 
 
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 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain. 
He has psychological clearance for the SCS trial. There is no documentation that other conservative therapies 
have been trialed. He still has several other modalities available to him as well as additional medications that he 
can trial. He does not have an evidence based indication for this procedure and does not meet the Medicare 
criteria. The services are not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a spinal cord stimulator (SCS) trial.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy (S9345) provided on October 28, 
2019, through October 30, 2019. 
 
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says CPT code S9345 has a status indicator of I 
and 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 S9345 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code S9345 has a status indicator of I. This means that CPT code S9345 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not 
been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy (S9345) 
provided on October 28, 2019, through October 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient stay for revision right total knee 
arthroplasty. 
 
You asked the Plan to pre-approve an inpatient stay for revision right total knee arthroplasty. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that replacement/revision total knee arthroplasty is 
covered when specific criteria is met. 
 
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 inpatient stay for revision right total 
knee arthroplasty. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found provided documentation does not support the need for inpatient stay as there is limited significant co-
morbidities identified, (along with level of function prior to surgery is noted as active and mobile.) Therefore, 
this enrollee does not meet the coverage criteria for the requested inpatient stay. The request is not medically 
reasonable or 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 an inpatient stay for revision right total knee arthroplasty have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an inpatient stay for revision right total knee 
arthroplasty.