Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat 
exchanger provided on April 10, 2020. 
 
You asked the Plan to pay for the perfusionist services (99190). You say that this equipment was provided to 
the enrollee during an inpatient stay and should be covered. The Plan denied your request. The Plan says this 
claim cannot be paid separately based on Medicare guidelines for inpatient services. The Plan says that this 
claim should be submitted to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all 
necessary covered services to the beneficiary either directly or under arrangements made with outside 
providers.  
 
This equipment was used during and after a surgical procedure by the facility.  Payment for this service would 
have been included under the facility claim. Payment to you for this service is the responsibility of the facility 
or hospital. Based on this information, we decided that Medicare rules for coverage of the perfusionist services 
(99190) have not been met. Therefore, we decided that the Plan does not have to pay for assembly and 
operation of pump with oxygenator or heat exchanger provided on April 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 3, 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 procedure codes 80157, 80177, 80201, 80162, 80159, and 80173 are not covered. 
 
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 80157 is carbamazepine; free. The definition of code 
80177 is levetiracetam drug screen. The definition of code 80201 is assay of topiramate. The definition of code 
80162 is assay of digoxin; total. The definition of code 80159 is clozapine drug assay. The definition of code is 
80173 is assay of haloperidol. 
 
We find that CPT codes 80157, 80177, 80201, 80162, 80159, and 80173 are not supported in the medical 
record. Specifically, there are not laboratory results for the billed date of service. 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 laboratory services rendered on January 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says the criteria is not met, based on a lack of enough conservative therapies. 
 
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 the injection. Our reviewer says that the 
requested injection is not medically reasonable or necessary. Our physician reviewer found there was no 
evidence provided that the enrollee had completed a full course of physical therapy, or had been performing 
regular excercises as part of a conservative treatment trial to justify more invasive treatments. Therefore, this 
request for Synvisc will be considered not 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc injection for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the lumbar Spine MRI (72148).
You asked the Plan to pre-approve the MRI. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says the criteria is not met for MRI of the lumbar spine without clinical re-evaluation of 6 week provider.
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 the MRI. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a 7-year history of low back pain with radiation to her lower extremities. There is no record of plain film analysis in the submitted records. She has no red flags to mandate immediate MRI of the lumbar spine absent a trial of conservative therapy. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve the lumbar Spine MRI (72148).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that the enrollee continues to need OT/PT/ST for 
progression to safe discharge home with home health services. She remains a medically complex patient, 
requiring nursing and physician monitoring and interventions. The Plan denied your request. The Plan says 
SNF care is not medically necessary at this time. The enrollee has reached a new level of function, and any 
training needed can be done prior to discharge from the IRF to a lower level of care. 
 
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 pre-approve the SNF services. Our reviewer says 
that daily skilled services are not medically necessary. Our physician reviewer found from a nursing 
perspective, the enrollee received oral and inhaled medications. The enrollee had stable vital signs. Her coccyx 
wound healed. Her tube feeds were stopped and she received free water flushes. Regarding rehabilitation 
services, the enrollee received PT, ST and OT in the acute hospital. The enrollee was at a moderate/maximal 
assist to dependent level with functional mobility. The enrollee was at a modified independent level with 
activities of daily living. She tolerated a mechanically altered diet with nectar thickened liquids. There are no 
identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The beneficiary 
does not require skilled nursing or therapy services on a daily basis. As a practical matter, this beneficiary does 
not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 
setting. 
 
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 services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve SNF services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sales tax (D9985) provided on February 18, 2020. 
 
You asked the Plan to pay for the sales tax. The Plan denied your request. The Plan says this service is not a 
covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The rules say that sales taxes 
are included in the calculation of the Medicare fee schedule. For this reason, Medicare does not make separate 
payment for sales tax. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the sales 
tax (D9985) provided on February 18, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the enrollee would like to gain strength before returning home. The Plan denied your request. The Plan says that the enrollee's needs are custodial in nature.
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 pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no daily skilled care needed - the enrollee is back at a level of care prior to 
the hospitalization. 
 
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 pre-approve the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity 
of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a urine culture (87086) provided on January 27, 2020. 
 
You asked the Plan to pay for a urine culture. You say that this service was not related to Hospice. The Plan 
denied your request. The Plan says coverage of this service is the responsibility of Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on January 21, 2020. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for a urine culture 
(87086) provided on January 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient telemedicine office visits 
(99204, 99213) provided April 24, 2020 to May 18, 2020. 
 
You asked the Plan to waive the copayment for the outpatient telemedicine office visits. You say that you 
believe that you should only have to pay for the actual office visit as the second telemed encounter was 
extremely short and only for the nurse practitioner to send over medications to the local pharmacy. The Plan 
denied your request. The Plan says the outpatient specialist telemedicine visit was processed correctly. For 
telemedicine services provided by a specialist, the specialist cost share applies. 
 
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 per preferred specialist visit for Physician/Practitioner services including doctor's office visits.  
 
You have been asked to pay $40 copayment per preferred specialist visit for the outpatient telemedicine office 
visits. the outpatient telemedicine office visits fall 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 the outpatient telemedicine 
office visits (99204, 99213) provided April 24, 2020 to May 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a biopsy provided by a participating 
provider on May 26, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you feel like you should 
only have to pay for the second biopsy because the first one was done in the wrong area. 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 $250 
copayment for outpatient surgery.  
 
You have been asked to pay a $250 copayment for an outpatient surgery. Since a biopsy was performed, the 
correct copayment has been applied. An outpatient surgery falls within the outpatient surgery 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 biopsy provided by a participating provider on May 26, 
2020.  
 
We note your complaint about not wanting to pay for the first biopsy because it was done incorrectly. Your 
complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crutch substitute (E0118).
You asked the Plan to pre-approve a crutch substitute. You say that the requested item is necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 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 a crutch substitute. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is no documentation that the crutch substitute at issue in this case is medically reasonable and necessary as there is insufficient published clinical literature demonstrating safety and effectiveness in the Medicare population. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a crutch substitute have not been met. Therefore, we decided that the Plan does not have to pre-approve a crutch substitute (E0118).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 1 standard power wheelchair for the enrollee.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says the physician must submit a face-to-face document.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the Mobility Assistive Equipment Face to Face Examination Report dated 8/6/2020 documents that the enrollee's mobility deficit can be safely resolved by a cane or walker. It is not documented that the enrollee's home environment can support the use of a wheelchair or POV. It is not documented that the enrollee can safely operate a PMD. 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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 1 standard power wheelchair for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve home care visits. 
 
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the documentation received does not meet the internal rules set by the plan. 
 
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 not provided any medical records for review. The requesting 
provider is contracted with the plan, so the plan should have been able to provide these records. Therefore, we 
decided that the Plan has to pre-approve home care visits.  
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk in tub (E1399).
You asked the Plan to pre-approve the walk in tub. You say that you would like reconsideration because the walk in tub is medically necessary for your major health conditions. The Plan denied your request. The Plan says the requested item is not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a walk in tub (E1399).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz Fx (J7321). 
 
You asked the Plan to pre-approve Supartz Fx. You say that the medication is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Supartz Fx. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the documentation does not support that 
Monovisc and Orthovisc (Hyaluronic acid) would likely be less effective, and/or would likely have adverse 
effects for you in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Supartz Fx have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Supartz Fx (J7321).