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

 
We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on 
February 6, 2020. 
 
You asked the Plan to pay for the pump assembly and operation. You say that you would like reconsideration 
because it takes 30 minutes to set up the machine and the perfusionist is required to remain in the operating 
room throughout the duration of the procedure. The Plan denied your request. The Plan says payment for this 
service is the responsibility of the facility to any vendor. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier 
other than the facility or hospital for services furnished to the beneficiary while an inpatient. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the pump assembly and operation have not been met. Specifically, payment for this service is 
included in the payment to the facility and is the responsibility of the facility to any vendor. Therefore, 
we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on 
February 6, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided by a 
participating provider on February 25, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you know people who 
had polyps removed and didn't have to pay anything. The Plan denied your request. The Plan says the correct 
copayment has been 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 $400 
copayment for outpatient surgery/outpatient hospital.  
 
You have been asked to pay a $400 copayment for a diagnostic colonoscopy. The rules say that, if during the 
course of the screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the 
growth, the appropriate diagnostic procedure classified as a colonoscopy with biopsy or removal should be 
billed. A diagnostic colonoscopy falls within the outpatient surgery/outpatient hospital 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 diagnostic colonoscopy provided by a participating 
provider on February 25, 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's therapy needs can be provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for osteomyelitis and 
sepsis. He had a right below the knee amputation. The enrollee's medical problems are stable. There are no 
identified problems that need inpatient medical management. There are no complex nursing or rehabilitation 
needs. The patient does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for 
physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy 
program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit 
from the 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of assistive reproductive technologies to achieve 
pregnancy. 
 
You asked the Plan to pre-approve treatment to achieve pregnancy. You say that in the past you were told that 
this was a covered benefit. The Plan denied your request. The Plan says the denial of authorization for these 
services is correct, because these services are not covered by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 
 
We looked at the file and Medicare rules. These services are not reasonable and necessary for the diagnosis or 
treatment of an illness or injury, or to improve the functioning of a malformed body member. Therefore, these 
services are not covered by Medicare for the requested purpose. Therefore, we decided that the Plan does not 
have to pre-approve use of assistive reproductive technologies to achieve pregnancy.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for autonomic nervous system function testing (95924) provided 
on November 25, 2019. 
 
You asked the Plan to pay for autonomic nervous system function testing. You say that this was medically 
necessary. The Plan denied your request. The Plan says the submitted report does not include the servicing 
provider's name or signature. 
 
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 95924 is testing of autonomic nervous system function; 
combined parasympathetic and sympathetic adrenergic function testing with at least 5 minutes of passive tilt. 
 
We find that CPT code 95924 is not supported in the medical record. Specifically, the submitted report for this 
service does not include physician information needed to verify this service. Based on this information, we 
decided that Medicare rules for coverage of autonomic nervous system function testing have not been met. 
Therefore, we decided that the Plan does not have to pay for autonomic nervous system function testing 
(95924) provided on November 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from December 16, 
2019, to December 17, 2019. 
 
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says care 
could have been provided in an observation setting. 
 
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 that the enrollee was admitted and treated with analgesics and evaluated by PT/OT. 
She was discharged home on December 17, 2019. The record did not show that at the time of inpatient 
admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including 
earlier 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 the acute inpatient hospital care provided from December 16, 2019, to December 
17, 2019.
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 you do not need  a 
team of specialized healthcare professionals, or supervision by a rehab physician. 
 
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 weakness and a fall. Your medical problems are stable. The 
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The medical record supports a need for physical 
and occupational therapy but it does not support a need for an intensive rehabilitation therapy 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 pre-approve lumbar spinal fusion procedure (22633). 
 
You asked the Plan to pre-approve lumbar spinal fusion procedure. You say that the enrollee would like to 
proceed with surgical treatment since he continues to deteriorate due to lack of mobility due to leg and back 
pain and progressive weakness in his legs The Plan denied your request. The Plan says the medical criteria for 
the requested surgery has not been met. 
 
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 lumbar spinal fusion procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the criteria for lumbar fusion not been met. There is no documentation of 
segmental instability with greater than 5mm of abnormal motion at each fusion segment. There is no 
documentation of previous fusion failure. Fusion surgery not medically needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar spinal fusion procedure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve lumbar spinal fusion procedure (22633).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 sensor. 
 
You asked the Plan to pre-approve a Dexcom G6 sensor. You say that this is medically necessary. The Plan 
denied your request. The Plan says that you do not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs and supplies are covered 
when the above criteria have been met. 
 
 
 
We looked at the file and Medicare rules. The file indicates you are not treated by insulin injections three or 
more times a day. Based on this information, we decided that Medicare rules for coverage of a Dexcom G6 
sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 
sensor.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided to the enrollee on May12, 2020. 
 
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 claim must be submitted to Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided to the enrollee on May12, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic exercises (97110) and therapeutic activities 
(97530) provided on February 1, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for therapeutic exercises and activities. You say that you do not agree with the 
denial. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services by an out-of-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 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 therapeutic exercises (97110) and therapeutic 
activities (97530) provided on February 1, 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 neuromuscular reeducation (97112) provided on February 4, 
2020. 
 
You asked the Plan to pay for the neuromuscular reeducation. You say that you would like reconsideration 
because the member has gone to this doctor for years. The Plan denied your request. The Plan says this service 
is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for neuromuscular reeducation (97112) provided on February 4, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $225 copayment charged for ambulance transport 
provided on April 16, 2020. 
 
You asked the Plan to waive this copayment. You say that you would like the Plan to waive this copayment. 
The Plan denied your request. The Plan says this copayment is a contractual obligation. 
 
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 $225 
copayment for ambulance transport. 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 $225 copayment charged for ambulance 
transport provided on April 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out of network physician services at the in-network 
coverage rate. 
 
You asked the Plan to pre-approve out of network services at the in-network rate. You say that the Plan should 
allow coverage for this out of network provider at the in-network rate. The Plan denied your request. The Plan 
says these services can be provided in network and you have the option to use your POS benefits to see this 
provider, but the contract is clear you will pay a higher cost share. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that in some circumstances with prior authorization you have the option to use out of network 
providers, however the cost share will be higher. 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. We found 
no exception that would require the Plan to pre-approve this service at the in-network rate. Therefore, we 
decided that the Plan does not have to pre-approve out of network physician services at the in-network 
coverage rate.
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 enrollee is not clinically appropriate 
for a lower level of care. The Plan denied your request. The Plan says the enrollee is receiving appropriate care 
at the current acute care facility. 
 
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 physician 
reviewer found that the enrollee was admitted to the current acute care hospital with COVID-19 and bacterial 
pneumonia, as well as acute respiratory failure. He was treated with antibiotics and mechanical ventilation. 
Trach was placed as well as PEG for tube feeds. He was diagnosed with metabolic encephalopathy, DVT, and 
new onset atrial fibrillation. Currently the enrollee is not following commands and is still being treated with 
antibiotics, but weaning attempts have initiated.  The enrollee appears to be gradually improving with 
requirement of additional short term acute care services (less than 25 days) for additional weaning and 
stabilization. The enrollee does not require services at the LTACH that are not already available at the current 
facility. Therefore, this request for LTACH services will be considered 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical service provided by an opted-out physician on 
August 22, 2019. 
 
You asked the Plan to pay for specialist service. You say that you have used this doctor for 30 years, trust her 
implicitly, and are requesting partial reimbursement. The Plan denied your request. The Plan says the denial of 
payment for this service is correct, because this provider has opted out of Medicare and is not eligible for 
payment. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
surgical service provided by an opted-out physician on August 22, 2019.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the lumbar spine. 
 
You asked the Plan to pre-approve these services. You say that you have severe pain and degeneration of the 
right hip. The Plan denied your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the records show that you have chronic hip 
pain and rheumatoid arthritis. You have received therapy for years. You have longstanding chronic pain and 
have tried alternative therapy. The requested MRI is reasonable and medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve magnetic resonance imaging (MRI) of the lumbar spine.  
 
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.