Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you would like the 
copayment waived since you were unable to select a network hospital. The Plan denied your request. The Plan 
says the copayment applied correctly in this case. 
 
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 $100 
copayment per days 1-10 for inpatient hospital care.  
 
You have been asked to pay a total cost share of $1,000 for the inpatient hospital stay (10 total days inpatient x 
$100 copayment). The service provided falls within the inpatient hospital care benefit category. Of note, the 
Plan charged you the in-network rate. 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 hospital 
stay provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for 
care in an LTACH. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care 
have not been met. The Plan says that the enrollee can safely receive the care needed in another setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for a 
diabetic foot ulcer.  The enrollee is not intubated/ventilated.  There is no evidence that the enrollee requires 
services that are not currently available.  There is no advantage in transferring the enrollee to the LTACH.  The 
enrollee can remain at the current ACH until such time no acute services are required.  The enrollee can then be 
transferred/discharged to a lower level of care for any ongoing long-term care 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from December 20, 2019 
to December 30, 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 the claims were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that HH PPS claims must report a 0023 revenue code line 
on which the first four positions of the HIPPS code match the code submitted on the RAP. 
 
We looked at the file and Medicare rules. The claims were not billed with the requested HIPPS code. 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 home health services rendered from December 20, 2019 
to December 30, 2019.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Clobetasol cream. 
 
You asked the Plan to pre-approve the Clobetasol cream. You say that the enrollee has been using this 
medication for years with success. You say that the enrollee has widespread psoriasis and requires a large 
amount to satisfy the area needed. The Plan denied your request. The Plan says the enrollee does not have a 
Part D benefit or separate pharmacy benefit under their contract. 
 
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 Clobetasol cream.  
 
Benefits for the Clobetasol cream 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex Superion Interspinous Spacers 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 experimental and investigational procedures are not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The spacer device is 
experimental. More research is needed to show safety and efficacy. Our physician reviewer found that the 
enrollee's condition does not meet Medicare 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 Vertiflex Superion Interspinous Spacers for the enrollee.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Everolimus. 
 
You asked the Plan to pre-approve the Everolimus. You say that the clinical information provided supports the 
need for the requested drug. The Plan denied your request. The Plan says the requested medication falls under 
Part D coverage, but the enrollee has no Part D pharmacy benefit under their contract. 
 
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 Everolimus.  
 
Benefits for the Everolimus 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the train-of-four (TOF) testing provided during 
intraoperative neuromonitoring (IONM) billed with code 95937. 
 
You asked the Plan to pay for the TOF testing. You say that this was done throughout the procedure and should 
be paid as you are billing for the high frequency stimuli during the spinal surgery. The Plan denied your 
request. The Plan says this is not the correct code for this service. 
 
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 95937 is Neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method. 
 
We find that CPT code 95937 is not supported in the medical record. Specifically, this code was used to 
describe TOF testing which is not adequately described by this code. TOF testing is not separately payable as it 
is integral to the performance of IONM. Based on this information, we decided that Medicare rules for 
coverage of the TOF testing have not been met. Therefore, we decided that the Plan does not have to pay for 
the train-of-four (TOF) testing provided during intraoperative neuromonitoring (IONM) billed with code 
95937.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on December 11, 2019 by an 
out of network (OON) provider. 
 
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 the services were rendered by an out-of-network provider without 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 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 the medical services provided on December 11, 
2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from March 24, 2020 to 
March 30, 2020. 
 
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 the claims were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that where required by law or regulation, report the Federal 
Information Processing Standards (FIPS) State and County Code of the place of residence where the home 
health service is delivered with code 85. 
 
We looked at the file and Medicare rules. The claims were not billed with the required FIPS code. 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 home health services rendered from March 24, 2020 to 
March 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee  
and billed under code 99152. 
 
You asked the Plan to pay for code 99152. You say that this claim should be paid. The Plan denied your 
request. The Plan says the records provided do not support the services 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 also find insufficient medical 
records were submitted to support the billing of code 99152. Medicare rules for coverage of code 99152. We 
are dismissing the appeal for code 92928 as this service was paid by the Plan have not been met. Therefore, we 
decided that the Plan does not have to pay for physician services provided to the enrollee and 
billed under codes 92928 and 99152.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan of the head and brain (70450) 
received on June 18, 2020. 
 
You asked the Plan to waive the copayment for a CT scan of the head and brain. You say that this service 
pertains to headaches related to COVID-19. 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 $200 
copayment for CT scans.  
 
The Plan has not offered to waive or modify copayments for services related to the COVID-19 pandemic when 
received from in-network providers. You have been asked to pay a $138.06 copayment for a CT scan of the 
head and brain received from an in-network provider. A CT scan of the head and brain falls within the 
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have 
been asked to pay less than or equal to 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 CT scan of the head and brain (70450) received on June 
18, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response with no transport provided on July 14, 
2020. 
 
You asked the Plan to pay for this service. You say that all the ambulance driver did was take your blood 
pressure and you chose not to go to the hospital. The Plan denied your request. The Plan says Medicare will not 
pay for ambulance response with no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport. The ambulance company did not provide transport services on July 14, 2020. The 
ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays 
for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response 
with no transport provided on July 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xolair 375 mg injections. 
 
You asked the Plan to pre-approve Xolair. You say that the service is not medically necessary. The Plan denied 
your request. The Plan says rules for coverage of Xolair have not been met. 
 
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 Xolair. Our reviewer says that the 
service is not medically necessary or reasonable. Our physician reviewer found there are no provided record 
documents that the enrollee has had a positive skin test or in vitro reactivity to a perennial aeroallergen. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Xolair have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xolair 375 mg injections.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee. 
 
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 this service was billed a previous claim billed by another provider. Both providers are 
within the same group and have the same specialty. Per Medicare guidelines for procedure to procedure 
editing, code 93010 is a column II code to the column I code 31500, but a modifier is allowed in order to 
differentiate between the services provided. Per review of medical records, the documents support the 
interpretation and report was performed and authenticated by the rendering provider and is supported as being 
separate and distinct.  However, per CMS an appropriate modifier is needed to represent the services as 
separate and distinct. Therefore, the recommendation for CPT code 93010 is to uphold the original denial as a 
modifier was not included on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code and when necessary the appropriate modifier.  
In this case, the claim submitted cannot be paid without the required modifier. Medicare rules for coverage of 
this service have not been met. Therefore, we decided that the Plan does not have to pay for physician services 
provided to the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a drug test provided on September 10, 
2020. 
 
You asked the Plan to waive the copayment for a drug test. You say that you do not feel that a drug test follow-
up makes sense. 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 $10 
copayment for lab services.  
 
You have been asked to pay a $10 copayment for a drug test. A drug test 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 a drug test provided on September 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan of the abdomen received on July 
9, 2020. 
 
You asked the Plan to waive the copayment for a CT scan of the abdomen. You say that you do not have 
money for these services. 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 $300 
copayment for advanced imaging or nuclear medicine services.  
 
You have been asked to pay a $300 copayment for a CT scan of the abdomen. A CT scan of the abdomen 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 a CT scan of the abdomen received on July 9, 2020.  
 
Your complaint about receiving erroneous or misleading information about your cost-sharing responsibility 
from your provider 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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the records provided support the need for care in the 
IRF. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for coverage of IRF 
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. 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 a COVID 19 infection. 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 pre-approve Orthovisc. 
 
You asked the Plan to pre-approve the Orthovisc. You say that the clinical information provided supports the 
need for the requested drug. The Plan denied your request. The Plan says , per the provider's order, the 
medication requested is to be supplied by a specialty pharmacy and the provider will not buy and bill. The Plan 
says that the medical provider is not supplying the medication and the rules for Part B coverage have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Orthovisc.  
 
Benefits for the Orthovisc provided through a pharmacy may be available under Medicare Part D. Contact the 
Plan that administers Part D benefits for further information concerning any benefits and appeal rights.