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
December 17, 2019.
You asked the Plan to pay for the assembly and operation of a pump. You say that you would like
reconsideration because it takes at least 30 minutes to set up the machine and the perfusionist is required to
remain in the operating room through 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 assembly and operation of a pump have not been met. Specifically, payment for this service is
included in the DRG 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
December 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ferritin assay rendered on February 17, 2020.
You asked the Plan to pay for these services. You say that the testing was ordered by your doctor. The Plan
denied your request. The Plan says the services were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that ferritin testing is covered when specific criteria
are met.
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 were not medically necessary. Our physician reviewer found the records show that you were evaluated
for chronic sinusitis and nose congestion (rhinitis). You reported fatigue and a ferritin assay was ordered.
Results of the initial testing were not obtained. The records do not support that the testing was reasonable and
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 the ferritin assay rendered on February 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on February
24, 2020.
You asked the Plan to waive the copayment for laboratory services. You say that you had to return to have the
correct test performed. You say that you shouldn't have to pay two copayments. The Plan denied your request.
The Plan says the copayment applied correctly.
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 $10
copayment for each Medicare-covered lab test.
You have been asked to pay a $10 copayment for the laboratory services. Laboratory services fall within the
"Outpatient diagnostic tests and therapeutic services and supplies" 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 laboratory services provided on February 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to approve continued inpatient psychiatric services from June 9, 2020
onward.
You asked the Plan to approve these services. You say that the services are medically necessary. The Plan
denied your request. The Plan says the services are 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 approve these services. Our reviewer says that the
services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on
June 4, 2020 with severe recurrent major depressive disorder with psychosis and major neurocognitive
disorder. Based on the submitted records, it is not expected that she will improve in a reasonable period of
time, as she does not have suicidal or homicidal ideation. Some auditory and visual hallucinations are noted,
but she is not bothered by them. She is complaint with treatment and not showing any acute threats to safety. It
does not appear that active treatment is taking place beyond the dates in question. The continued services are
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 approve continued inpatient psychiatric services from June 9, 2020 onward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on December 18, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not covered.
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 services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided on December 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the gastrointestinal pathogen panel provided on December
17, 2019.
You asked the Plan to pay for the services provided. You say that the services were provided per the physicians
request. The Plan denied your request. The Plan says screening services without a valid medical diagnosis
related to the health of the enrollee are not a benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
In this case, there were insufficient records provided to show the results of this testing would be used to
determine a specific diagnosis or determine a specific treatment strategy for disease or illness present in the
enrollee at the time of service. The test at issue in this appeal was requested for screening purposes. Medicare
does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the
gastrointestinal pathogen panel provided on December 17, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the assistant surgeon services during a laparoscopic enterolysis and
paraaortic lymph node dissection provided on December 16, 2019.
You asked the Plan to pay for the assistant surgeon services. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says that the services rendered are not a covered benefit.
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary
are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment
restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to
establish medical necessity. In this case, you billed assistant surgery services for CPT code 38570. The
Medicare Fee Schedule Database contains a surgical indicator of 0 for this procedure.
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 assistant surgeon services. Our reviewer
says that the documentation supports that the surgical assistant services provided were medically necessary.
Our physician reviewer found the enrollee underwent a laparoscopic enterolysis and paraaortic lymph node
dissection for ovarian cancer. This is a surgery that requires an assistant. The procedure was performed by the
surgeon and a surgical assistant. The assistant was not a physician. The documentation does not provide any
information on why the surgeon was not paid for the procedure which as billed as 38570. Based on the criteria
outlined above, surgical assistant services were 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 assistant surgeon services have been met. Therefore, we decided that the
Plan has to pay for the assistant surgeon services during a laparoscopic enterolysis and paraaortic lymph node
dissection provided on December 16, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from December 10,
2019 through December 11, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The
Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found the review has determined that the record did not show that at the time of inpatient
admission the admitting physician reasonably expected that the patient's necessary hospital care (including
earlier emergency department (ED) and/or observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for the acute inpatient hospital care provided from December 10, 2019 through
December 11, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided on December 4, 2019 to
January 30, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that you disagree with the denial. The Plan
denied your request. The Plan says that the services were not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer
says that the services were medically necessary. Our physician reviewer found the enrollee presented to the
emergency department (ED) with right leg pain. He was admitted and underwent a procedure with the common
iliac artery and an abdominal aortic aneurysm. Post-procedure he required mechanical ventilation and
vasopressor therapy. He developed a Klebsiella pneumonia ischemic colitis requiring an exploratory
laparotomy with a transverse colostomy, and a deep tissue injury to the right heel. He required IV antibiotics
and a PEG for nutritional support. He required an angioplasty and stent after occlusion of the right common
iliac artery at the site of the anastomosis. The records support that, at the time of the 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 been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided on December 4, 2019 to January 30, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the TDAP vaccine you had on February 27, 2020.
You asked the Plan to pay for the vaccine. You say that you didn't know that you could not get this vaccine.
The Plan denied your request. The Plan says this is not covered under Part B.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The
Plan follows the same rules.
The records do not show that you have been injured or directly exposed to any illness related to the vaccine.
Therefore, we decided that the Plan does not have to pay for the TDAP vaccine you had on February 27, 2020.
Benefits for the vaccine may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided on January 20, 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 A 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 January 20,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider on March 3, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 services at
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider
on March 3, 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.
You asked the Plan to pre-approve IRF care. You say that this would greatly benefit and impact your ability to
perform daily activities and to be able to safely return to your previous level of independence. The Plan denied
your request. The Plan says that you can safely receive the services you need in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. You are currently living in the home and have
developed progressive weakness. There are no complex medical conditions which require inpatient
management. You do not require management by a rehabilitation physician at least three days a week. You do
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an
intensive rehabilitation therapy program. You do have a documented need for skilled therapy, including
physical and occupational therapy, but there is no documented need for an intensive, complex interdisciplinary
rehabilitation course. 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. Our physician reviewer found
that your 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.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was transferred to
this hospital due to a nurses' strike, and you are appealing with medical records. The Plan denied your request.
The Plan says that the denial of authorization for inpatient level of care is correct, because there is no
attestation that the enrollee's anticipated hospital stay would be expected to exceed 2 midnights.
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 pre-approve acute inpatient hospital care. Our
reviewer says that the documentation supports that the criteria for inpatient hospital care are met in this case.
Our physician reviewer found at the time of inpatient admission, the admitting physician reasonably expected
that the enrollee's necessary hospital care (including earlier emergency department and/or observation care)
would span at least 2 midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pre-approve acute inpatient hospital care.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for extraction, erupted tooth or exposed root (elevation and/or
forceps removal) (D7140) and resin-based composite - two surfaces, anterior (D2331) provided on February
22, 2020.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the
denied charges. The Plan denied your request. The Plan says the services are not a covered benefit under the
plan.
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. The services are not listed in your EOC as a covered benefit; therefore,
the services are not covered. Therefore, we decided that the Plan does not have to pay for extraction, erupted
tooth or exposed root (elevation and/or forceps removal) (D7140) and resin-based composite - two surfaces,
anterior (D2331) provided on February 22, 2020.