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

We decided that the Plan does not have to pre-approve facial surgery (11043). 
 
You asked the Plan to pre-approve the surgical procedure. You say that the masses keep returning and the 
surgery is medically necessary. The Plan denied your request. The Plan says the requested service is considered 
cosmetic and non-covered. 
 
The Plan follows Medicare rules. Medicare rules say that corrective facial surgery will be considered cosmetic 
rather than reconstructive when there is no functional impairment present. 
 
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 surgical procedure. Our reviewer 
says that the surgery is not medically necessary. Our physician reviewer found the clinical documentation is 
insufficient to demonstrate that extraction of facial fat lumps is medically reasonable and necessary for the 
enrollee 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 the surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facial surgery (11043).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 23, 2019. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because the documentation 
submitted does not include a valid physician order, lab requisition, or medical records to support the codes 
billed or the Place of Service (POS) code billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician 
order or clear intent to order the specific lab services billed on this claim. Based on this information, we 
decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan 
does not have to pay for laboratory services provided on August 23, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for post-stabilization care provided to the enrollee from January 
12, 2020, at 10:04 a.m. through January 13, 2020. 
 
You asked the Plan to pay for the post-stabilization care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the stay is not medically necessary. 
 
 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 post-stabilization care. Our physician 
reviewer found the review indicates that all post-stabilization care provided after 10:03 a.m. on January 12, 
2020, to 4:00 p.m. on January 13, 2020, at the non-Plan facility was not medically necessary or reasonable. The 
treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not 
stable for transfer on any dates of service.  
 
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 post-stabilization care have not been met. Therefore, we decided that the 
Plan does not have to pay for post-stabilization care provided to the enrollee from
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray (71045) provided on March 26, 2020. 
 
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the claim does not include the correct address for the 
facility where the services were provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that claims for services furnished in all places of service other than a beneficiary's home must include 
information specifying where the service was provided.  
 
We find that CPT code 71045 is not supported in the medical record. Specifically, the corrected claim that was 
submitted does not include information specifying where the service was provided. Of note, the address listed 
on the claim is the billing provider's address and not the skilled nursing facility. Based on this information, we 
decided that Medicare rules for coverage of the chest x-ray have not been met. Therefore, we decided that the 
Plan does not have to pay for the chest x-ray (71045) provided on March 26, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vedolizumab (Entyvio). 
 
You asked the Plan to pre-approve Entyvio. You say that the enrollee had an infusion reaction, likely related to 
Remicade. The Plan denied your request. The Plan says the documentation does not show that the enrollee has 
had prior therapy or cannot use Stelara. 
 
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 Entyvio. Our physician reviewer found 
that the enrollee has a diagnosis of Crohn's disease of the large intestine without complications. The Plan 
requires a trial of Stelara before they will approve the requested drug. The documentation does not show that 
the enrollee has tried and failed the required drug. The documentation does not support that Stelara would 
likely be less effective, or would likely have adverse effects for the enrollee. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vedolizumab (Entyvio).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Prolia rendered on June 9, 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 services were not medically necessary. 
 
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 pay for these services. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
osteoarthritis. The use of Prolia is not supported by the Medicare-approved compendia for the treatment of 
osteoarthritis. The services are therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for Prolia.  
 
Local Coverage Determination (LCD) L33394 referenced by the Plan is for the incorrect jurisdiction and was 
not used in the QIC's determination.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the cervical spine. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no description of prior treatments or responses to prior treatments for neck pain. 
 
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 MRI is not medically reasonable or necessary. Our physician reviewer found you are noted to have 
chronic neck pain and chronic low back pain without neurologic symptoms. Prior c-spine x-rays showed early 
degenerative changes.  There has been no recent trauma. The documentation does not support that a MRI of the 
neck is currently medically necessary or reasonable. 
 
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 MRI of the cervical spine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral evaluation (D0120) and periodontal maintenance 
(D4910) provided on July 13, 2020. 
 
You asked the Plan to pay for the dental services. You say that you have been getting 3 cleanings per year since 
2010. You say that you are not sure if you deny all periodontists or just this office. You also say that you need 
to have 3 cleanings per year covered. The Plan denied your request. The Plan says the provider in this case is 
not a network dental provider. The Plan also says that dental services that you receive out of network are not 
covered. 
 
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. 
 
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 when you receive them out of network. Therefore, we decided that the 
Plan does not have to pay for the oral evaluation (D0120) and periodontal maintenance (D4910) provided on 
July 13, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for continued inpatient hospital care provided from May 19, 2020, to May 
20, 2020. 
 
You asked the Plan to pay for inpatient hospital care. You say that inpatient level of care is substantiated by the 
clinical evidence present. The Plan denied your request. The Plan says that the denial of payment for these 
services is correct, because inpatient level of care was not medically necessary for these dates. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for inpatient hospital care. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee was bactermic with sepsis syndrome and clearly meets criteria for inpatient 
hospital level of 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 inpatient hospital care have been met. Therefore, we decided that the Plan has to 
pay for continued inpatient hospital care provided from May 19, 2020, to May 20, 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for PT/INR monitoring system and related supplies purchased 
on May 1, 2020 from an non-Medicare/certified provider. 
 
You asked the Plan to pay for monitoring system and supplies. You say that you are appealing this claim for 
this piece of medical equipment and for reconsideration for payment. The company does not file claims with 
insurance companies so there isn't a Medicare CPT code to use. The Plan denied your request. The Plan says if 
you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of 
the services you receive. 
 
The plan must follow Medicare rules. Medicare rules say that this PPO plan will generally cover your medical 
care as long as the care you receive is considered medically necessary and you receive your care from a 
provider who is eligible to provide services under Original Medicare. As a member of the PPO plan you can 
receive your care from either a network provider or an out-of-network provider. 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 PT/INR monitoring system and related supplies purchased on May 1, 2020 from an non-Medicare/certified 
provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transportation services (A0427, A0428, 
A0425) provided on March 15, 2020, and March 17, 2020. 
 
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 Medicare Hospice benefit, through fee-
for-service Medicare, covers all Hospice care from the effective date of election to the date of discharge or 
revocation. During the election, fee-for-service Medicare also covers attending physician services and all care 
unrelated to the terminal illness starting on the date of the Hospice election until the first day of the month 
following the month in which Hospice is revoked or discharged. 
 
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. 
 
Medicare Hospice benefits were ended on March 15, 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 the ambulance transportation 
services (A0427, A0428, A0425) provided on March 15, 2020, and March 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of inpatient mental health care. 
 
You asked the Plan to pre-approve continuation of inpatient mental health care. You say that the stay is 
medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continuation of inpatient mental health 
care. Our physician reviewer found based upon review the records provided it was not expected this enrollee 
would improve in a reasonable period of time for the dates in question as they did not have suicidal or 
homicidal ideation noted and denied any auditory or visual hallucinations. The enrollee was compliant with 
treatment while not showing any acute threats to safety. It did not appear medically necessary and reasonable to 
have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the 
dates in question as they did not have dangerousness to self or others but was compliant with their treatment. 
The health plans denial of continued inpatient psychiatric services is appropriate. This enrollee did not appear 
to require inpatient mental health treatment beyond the date in question as they were not a danger to herself or 
others and did not have any auditory or visual hallucinations while being cooperative with treatment. It did not 
appear that active treatment was taking place beyond the date in question. It did not appear that the services 
were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis beyond the date in 
question. This enrollee was treated under an individualized treatment plan found in the record. It did appear 
 
 
that the records were supervised and evaluated by a physician. Based upon review the records provided for the 
admission of this enrollee does not meet the criteria for continued acute inpatient mental health treatment for 
the dates in question of December 1, 2020, forward as this enrollee was not shown to be a danger to themselves 
or others. The enrollee was not showing any auditory or visual hallucinations and was cooperative/compliant 
with treatment while not showing any threats the safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuation of inpatient mental health care have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continuation of inpatient mental health care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services billed for date of service February 16, 
2020. 
 
You asked the Plan to pay for the surgical services. You say that this should be paid. The Plan denied your 
request. The Plan says the documentation submitted reflects a different date of service than the billed date of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must submit sufficient documentation 
to determine whether payment is due and must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. 
 
In this case, the operative note has discrepancies which report that services were performed on February 12, 
2020 and other places in which the billed date of service is shown. It cannot be confirmed from the records that 
the services at issue were provided on February 16, 2020 based on the documentation. Therefore, we decided 
that the Plan does not have to pay for the surgical services billed for date of service February 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthrocentesis, aspiration and/or injection, major joint or 
bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and 
reporting (CPT Code 20611 59 LT and RT X2) provided on December 5, 2019. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
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 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 services. Our physician reviewer found 
based on the medical records provided there is no documentation that CPT Code 20611 59 LT and RT is 
supported. The records document injection of bilateral tendon sheaths not arthrocentesis, aspiration and/or 
 
 
injection of a major joint or bursa. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, 
subacromial bursa); with ultrasound guidance, with permanent recording and reporting (CPT Code 20611 59 
LT and RT X2) provided on December 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wheelchair with detachable footrest (E1140) provided on 
March 31, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the wheelchair with detachable footrest. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says the provider in this case is 
not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider or supplier must be enrolled in 
Medicare to receive payment for services furnished. 
 
We looked at the file and Medicare rules. The information in the case file indicates that the durable medical 
equipment was purchased from a supplier that is not enrolled in the Medicare program. Based on this 
information, we decided that Medicare rules for coverage of the wheelchair with detachable footrest have not 
been met. 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 wheelchair with detachable footrest (E1140) provided on 
March 31, 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 outpatient services provided on October 18, 2019. 
 
You asked the Plan to pay for the outpatient services. The Plan denied your request. The Plan says that 
generally, the enrollee must receive care from a network provider. In most cases, care received from a non-
network provider will not be covered. 
 
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 
outpatient services. 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 outpatient services provided on October 18, 2019.