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

 
We decided that the Plan does not have to pay for critical care services (99291) provided on February 21, 2020. 
 
You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the documentation submitted does not 
support the service 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, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the record. Specifically, the record does not indicate the 
amount of time that critical care services were rendered on the billed date of service. Based on this information, 
we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we 
decided that the Plan does not have to pay for critical care services (99291) provided on February 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve new breast implants. 
 
You asked the Plan to pre-approve the implants. You say that your chest wall is starting to move to the left. The 
Plan denied your request. The Plan says this is considered a cosmetic procedure. 
 
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 implants. Our reviewer says that the 
requested implants are not considered medically reasonable and necessary in this case. Our physician reviewer 
found as the documentation supports that the original surgery was performed for cosmetic reasons, treatment of 
the complication should be considered relatively cosmetic as well. Thus, breast implant replacement should be 
considered cosmetic surgery and not 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 the implants have not been met. Therefore, we decided that the Plan does not 
have to pre-approve new breast implants.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Remicade once every four weeks. 
 
You asked the Plan to pre-approve Remicade once every four weeks. You say that receiving this drug once 
every six weeks is not helping the enrollee. The Plan denied your request. The Plan says the requested 
frequency is not supported. 
 
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 Remicade once every four weeks. Our 
reviewer says that the requested dosage of Remicade is not medically necessary. Our physician reviewer found 
the enrollee has fistulizing Crohn's disease with persistent perianal activity despite dose-optimized Remicade. 
Clinical criteria alone, regardless of whether therapeutic drug monitoring demonstrated that a desired drug 
trough serum level target has been achieved, would support that member has failed Remicade and may warrant 
a change in therapeutic regimen. The medical necessity is not supported in this case by available records for 
dose-maximization of Remicade to 10mg every 4 weeks, particularly without clarity as to whether the enrollee 
has developed drug antibodies. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Remicade once every four weeks have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Remicade once every four weeks.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $40 copayments charged for telehealth mental health visits 
provided on June 4, 2020 and June 8, 2020. 
 
You asked the Plan to waive these copayments. You say that these copayments should be waived due to Covid 
19. The Plan denied your request. The Plan says these copayments were for outpatient mental health services, 
not for Covid 19 testing. 
 
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 $40 
copayment for outpatient mental health services provided via telehealth. 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 $40 
copayments charged for telehealth mental health visits provided on June 4, 2020 and June 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 87633, 87798, 87498, 87486, 
87541, 87581, 87640 and 87635 provided on April 22, 2020. 
 
You asked the Plan to pay for the laboratory 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 87633, 87798, 87498, 87486, 87541, 87581, 87640 and 87635 are not supported in the 
medical record. Specifically, the documentation did not include laboratory results for the billed date of service. 
In addition, the documentation does not support evidence of an established relationship between the enrollee 
and the ordering physician. Based on this information, we decided that Medicare rules for coverage of the 
laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services coded 87633, 87798, 87498, 87486, 87541, 87581, 87640 and 87635 provided on April 22, 
2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a physical therapy evaluation to be rendered by an out 
of network (OON) provider. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are in-network providers available to render the 
service requested. 
 
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 service at issue in this appeal. We found no exception that would require the 
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve a physical 
therapy evaluation to be rendered by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the x-ray on May 19, 2020. 
 
You asked the Plan to waive the deductible for the x-ray. You say that you are appealing your cost-share 
responsibility for the services you received. The Plan denied your request. The Plan says they reprocessed the 
claims to remove the $18.74 deductible charges. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received the x-ray on May 19, 2020. At the time of services rendered you had 
not met your $750 deductible; therefore, you have been asked to pay $77.98 for the services to apply to your 
deductible. 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 deductible for the x-ray on May 19, 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 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 can safely receive the services needed in other settings. 
 
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's medical status does not currently 
require intensive physician and nursing oversight only in an IRF. The patient may benefit from multiple 
therapies such as physical and occupational therapy but the documentation does not support that the patient's 
functional status requires or can tolerate an intensive rehabilitation therapy program provided in an IRF. 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: 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 the services can be safely received in other settings, such as skilled nursing facility, home with home health services, or home with outpatient therapy.

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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care.  Ongoing pain medication and other medication management, wound/skin care, and daily therapy can be provided at a SNF. A less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted period. An IRF intensity is not warranted.

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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  pneumatic compression devices. 
 
You asked the Plan to pre-approve the requested devices. The Plan denied your request. The Plan says the 
device for the prevention of blood clots during and after surgery is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file, and Medicare rules. The documentation shows the items were ordered for the 
enrollees arthroscopic surgery to prevent deep vein thrombosis. A PCD for the purpose of prevention of 
venous thromboembolism is excluded from coverage. Based on this information, we decided that Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve  
pneumatic compression devices.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a follow up office visit provided by an out-of-network provider on 
December 30, 2019. 
 
You asked the Plan to pay for a follow up office visit. You say that this was just a follow-up appointment for a 
surgery. The Plan denied your request. The Plan says that prior authorization was not obtained. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has failed to provide a 2019 Evidence of Coverage. Therefore, we 
decided that the Plan has to pay for a follow up office visit provided by an out-of-network provider on 
December 30, 2019. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assisted living facility care provided to the enrollee on March 
24, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says services rendered by non-participating 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 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 assisted living facility care provided to the 
enrollee on March 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nerve conduction studies (95911), needle 
electromyography (95885, 95886, 95887), neuromuscular junction testing (95937), and the ultrasound (76882) 
rendered by the out of network (OON) provider on November 26, 2019. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. 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 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 nerve conduction studies (95911), needle electromyography (95885, 95886, 
95887), neuromuscular junction testing (95937), and the ultrasound (76882) rendered by the out of network 
(OON) provider on November 26, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus Gene Panel provided on March 30, 2020. 
 
You asked the Plan to pay for the Tempus Gene Panel. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered were not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that molecular pathology services such as Tempus Gene 
Panel are only covered for certain indications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the Tempus Gene Panel. Our reviewer says 
that the documentation does not support that the services rendered were medically reasonable or necessary. Our 
physician reviewer found the enrollee has a reported diagnosis of Malignant neoplasm of the gallbladder. The 
documentation contains the cytology results of a fine needle aspiration, and genomic variants. There are no 
additional clinical records. The documentation does not support that the results of the Tempus Gene Panel will 
directly impact the treatment or management of the enrollee. Therefore, the enrollee did not meet criteria for 
the services rendered. 
 
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 Tempus Gene Panel have not been met. Therefore, we decided that the Plan 
does not have to pay for the Tempus Gene Panel provided on March 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on January 29, 2020 to February 8, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for 
payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that 
the member's primary care physician did not refer these services. 
 
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 
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 lab work provided on January 29, 2020 to 
February 8, 2020 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 visit for the evaluation and management of an 
established patient (99348) rendered by the out of network (OON) provider on March 16, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service 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 this service. Therefore, we decided that the Plan does not 
have to pay for the home visit for the evaluation and management of an established patient (99348) rendered by 
the out of network (OON) provider on March 16, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from February 6, 2020 
through February 8, 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 that the stay is 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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the review has determined that the record showed that at the time of inpatient admission the 
admitting physician reasonably expected that the patient's 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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from February 6, 2020 through February 8, 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.