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

 
We decided that the Plan does not have to waive the copayment for an X-ray of the knee (73562) performed on 
June 25, 2020. 
 
You asked the Plan to waive the copayment for an X-ray of the knee. You say that you did not expect a 
copayment for the X-ray. The Plan denied your request. The Plan says the correct copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for Medicare-covered X-ray and ultrasounds.  
 
You have been asked to pay a $38.68 copayment for an X-ray of the knee. An X-ray of the knee falls within the 
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have 
been asked to pay less than or equal to the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an X-ray of the knee (73562) performed on June 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided on April 17, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this 
service is included in the Part DRG payment 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. Payment for all fees related to this service would have been included under the facility claim. 
Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on April 17, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant surgeon services provided on June 4, 2020. 
 
You asked the Plan to pay for incision and drainage of abscess (10060-AS). You say that the Plan should pay 
this claim. The Plan denied your request. The Plan says this service is not payable. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with an allowable 
Physician Fee Modifier.   
 
The AS modifier is not among the allowable Physician Fee Modifiers for procedure code 10060. Based on this 
information, we decided that Medicare rules for coverage of services billed with the AS modifier have not been 
met. Therefore, we decided that the Plan does not have to pay for assistant surgeon services provided on June 
4, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone imaging whole body scan. 
 
You asked the Plan to pre-approve bone imaging whole body scan. You say that the requested bone imaging 
whole body scan is medically necessary. The Plan denied your request. The Plan says the requested bone 
imaging whole body scan is not medically necessary. 
 
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 bone imaging whole body scan. Our 
reviewer says that the requested bone imaging whole body scan is not medically necessary. Our physician 
reviewer found the enrollee is with a diagnosis of malignant neoplasm of the overlapping sites of bladder. Per 
NCCN guidelines, bladder cancer 6.2020 page BL-1, a bone scan is not an indicated initial staging tool for 
bladder cancer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone imaging whole body scan have not been met. Therefore, we decided that 
the Plan does not have to pre-approve bone imaging whole body scan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve block injections for the enrollee. 
 
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied 
your request. The Plan says the requested procedure does not have enough evidence that consistently shows 
proof of benefit for this condition. 
 
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 injections. Our reviewer says that 
the requested injections are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the effectiveness of genicular nerve blocks to treat knee pain has not been established. 
Genicular nerve blocks are considered experimental/investigational in nature. As such, right genicular nerve 
block to treat chronic knee pain is not medically reasonable and 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular nerve block injections for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of home health care services. 
 
You asked the Plan to pre-approve the continuation of home health care services. You say that the continuation 
of home health care services is medically necessary. The Plan denied your request. The Plan says the 
continuation of home health care services is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 continuation of home health care 
services. Our reviewer says that the continuation of home health care services is not medically necessary. Our 
physician reviewer found the records do not show that skilled nursing services are required to effectively 
provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a 
maintenance program to maintain the enrollee's condition and/or prevent deterioration. The enrollee has had 
prior SN and was educated in disease management. There are no complex wounds, new enteral feedings or 
other SN need. The records do not show that skilled therapy is needed to effectively provide treatment, care, 
and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance 
program to maintain the enrollee's level of function and/or prevent deterioration. The enrollee's functional level 
does not require ongoing skilled therapy. A home exercise program has been established and it was felt that the 
enrollee has reached maximum potential with physical therapy. As the enrollee does not require skilled therapy 
or skilled nursing services the enrollee does not meet the definition of home health aide services per Section 
 
 
50.2 and the request for  home health aide services are not reasonable and necessary for the treatment of the 
enrollee's illness or injury by the skilled professional staff. 
 
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 continuation of home health care services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the continuation of home health care services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health care provided to the enrollee on 
February 13, 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 the enrollee did not have prior authorization for out of network care. 
 
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 Plan contract states outpatient mental health requires a 
referral.  
 
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 outpatient mental health care provided to the 
enrollee on February 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office outpatient visit (99214) provided on March 20, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for outpatient visit. You say that telemedicine does not require prior authorization. 
The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services 
rendered 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 office outpatient visit (99214) provided on 
March 20, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no contractual obligation to cover services that are not medically necessary.
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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the requested procedure is supported for predominantly axial pain that is not associated with
radiculopathy or neurogenic claudication. The office notes indicate the patient has chronic low back pain with
radiation into the buttock and leg. Conservative care including physical therapy was not documented. Repeat
denervation procedures involving the same joint will only be considered medically necessary if the patient
experienced more than 50% improvement of pain and improvement in patient specific ADLs documented for at
least 6 months. This was not documented in the submitted medical records.
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 pre-approve radiofrequency ablation for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology services (70553) provided on December 5,
2019.
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the services were not emergent or pre-authorized. There were network
providers available.
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 services 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 these services. Therefore, we decided that the
Plan does not have to pay for the radiology services (70553) provided on December 5, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on April 28, 2020 and 
billed under codes 80177, 80201, 80162, 80159, and 80173. 
 
You asked the Plan to pay for lab services provided to the enrollee. You say that this claim should be paid. The 
Plan denied your request. The Plan says while codes G0483 and 80307 were paid, the remaining codes were 
denied based on the specimen type. Blood specimen collection is by venipuncture, however, the specimen 
collected for the billed code is not documented; therefore, not all of the billed service can be verified. It is 
noted multiple attempts were made to obtain additional information from the provider. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. The denied codes cannot be paid due to an issue with 
the reported specimen type. Therefore, we decided that the Plan does not have to pay for lab services provided 
to the enrollee on April 28, 2020 and billed under codes 80177, 80201, 80162, 80159, and 80173.
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 the criteria for 
coverage of an IRF admission have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that 
you do 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. Our 
physician reviewer also found that there is not a reasonable expectation that you will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ramucirumab and Keytruda. 
 
You asked the Plan to pre-approve Ramucirumab and Keytruda. You say that the requested Ramucirumab and 
Keytruda are medically necessary. The Plan denied your request. The Plan says the requested Ramucirumab 
and Keytruda are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Ramucirumab and Keytruda. Our 
reviewer says that the requested Ramucirumab and Keytruda are not medically necessary. Our physician 
reviewer found the enrollee is diagnosed with non-small cell lung cancer. The combination of Ramucirumab 
and pembrolizumab is not FDA approved. Also, this enrollee has progression on pembrolizumab. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ramucirumab and Keytruda have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Ramucirumab and Keytruda.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient mental health care. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that the enrollee still needs inpatient 
care and without it will not get better. The Plan denied your request. The Plan says the denial of authorization 
for inpatient mental health care for October 15, 2020 and beyond is correct. 
 
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 inpatient mental health care. Our 
reviewer says that the enrollee does not meet the Medicare criteria for continued inpatient mental health care. 
Our physician reviewer found based upon review of the records, it was not expected that 
this enrollee would improve in a reasonable period (the date in question) as 
he was not showing any dangerousness to self or others, no auditory or visual hallucinations, and no abnormal 
behaviors. The enrollee was noted to be slow in mentation however appeared brighter. It does 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. It does not appear that active treatment. It 
does not appear that continued services were reasonable expected or medically necessary to improve the 
enrollee's condition, or for the purpose of diagnosis.  
 
 
 
The records do not include an individualized treatment plan; however, the entire record is not present. The 
services were supervised and evaluated by a physician. 
 
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 mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continued inpatient mental health care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assembly and operation of a pump with oxygenator or 
heat exchanger. You asked the Plan to pay for the assembly and operation of a pump with oxygenator or heat 
exchanger. You say that CPT code 99190 is for the set up and operation of the heart lung machine for the 
enrollee's open heart surgery. The perfusionist is required to be in the operating room during the length of the 
procedure. The Plan denied your request. The Plan says Medicare does not pay any provider or supplier other 
than the hospital for services furnished to the beneficiary while an inpatient in hospital. 
 
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility 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. You 
provided physician services to the enrollee while in inpatient hospitalization status in a facility. Payment for 
this service would have been included under the facility claim for the inpatient hospitalization. Payment to you 
for this service is the responsibility of the facility or hospital. Therefore, the plan is not required to pay you 
separately for this claim. Therefore, we decided that the Plan does not have to pay for assembly and operation 
of pump with oxygenator of heart exchanger (99190) provided on September 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair accessories. 
 
You asked the Plan to pre-approve the requested services. You say that the lift is needed to help maintain some 
independence. The Plan denied your request. The Plan says a seat lift does not serve a medical purpose, and the 
display, bracket, and extension cable cannot be requested separately. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
A power seat elevation system was requested. We looked at the file and the rules. The item at issue does not 
serve a purpose that is primarily medical in nature. 
 
 
 
A figure 8 bracket, egg switch extension cable, and alternative controls and electrons were also requested. We 
looked at the file and the rules. Code K0108 must not be used for any component or feature of an expandable 
controller at the time of initial issue. The requested items are included in the approved expandable control 
system. They are not separately approved. Based on the information provided, we decided that the Medicare 
coverage rules have not been met. Therefore, we decided that the Plan does not have to pre-approve wheelchair 
accessories.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on June 5, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you fell in the bathroom and could not get 
back up on your own. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 5, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on June 5, 2020.