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

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has back pain and 
numbness. The requested Superion spacer is considered experimental in nature, as more research is needed to 
show safety and efficacy. 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 pre-approve a Vertiflex Superion spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the stair lift (E1399) and the handling of this device (99002) 
provided on August 10, 2020. 
 
You asked the Plan to pay for this item/service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this item is not a covered benefit under your 
contractual policy or by Medicare. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate for you in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pay for the stair lift (E1399) and the handling of this 
device (99002) provided on August 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the wound care provided from July 2, 2020, 
to July 30, 2020. 
 
You asked the Plan to waive the copayment for the wound care. You say that this was not minor surgery and 
this is getting too expensive. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
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 each Medicare-covered outpatient hospital facility visit.  
 
You have been asked to pay a $195.06 copayment, which is less than the standard copayment amount for the 
skin surgery because you reached your maximum out-of-pocket amount. The skin surgery falls within the 
'Outpatient Surgery, including services provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers' 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 wound care provided from July 2, 2020, to July 30, 
2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the endoscopy provided on July 6, 2020. 
 
You asked the Plan to waive the copayment for the endoscopy. You say that this is a financial burden to have 
to pay such a high cost for this service. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
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 per day for outpatient procedures and services, including but not limited to diagnostic and 
therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical 
center.  
 
You have been asked to pay a $250 copayment for the endoscopy. The endoscopy falls within the ?Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers? benefit 
category. The record shows you were charged for the endoscopy and not for the colonoscopy. 
 
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 endoscopy provided on July 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the TempusiXPancreatic Gene Panel provided on June 15, 
2020. 
 
You asked the Plan to pay for the gene panel. You say that you would like reconsideration because this service 
was medically necessary to assist in the treatment, prognosis and diagnosis of the member's cancer. The Plan 
denied your request. The Plan says comprehensive genomic profile testing is not defined as a targeted panel by 
Mo1DX. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
 
 
 
 
 
 
 
The test at issue in this appeal, the gene panel, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
TempusiXPancreatic Gene Panel provided on June 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from August 15, 2020, 
to August 18, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that you brought your medications to the 
hospital with you, but were told not to use them. The Plan denied your request. The Plan says these drugs are 
not Part B covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided from August 15, 2020, to August 18, 2020.  
 
Benefits for the self-administered drugs 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you cannot breathe and need extra care 
with an oxygen machine. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements for approval of LTACH care. The Plan says that the enrollee can receive the care needed in 
another setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee's ongoing care needs include supplementation oxygen and intermittent 
BiPAP, nebulizer treatments, oral medications, surveillance laboratory studies, and therapy services. The 
documentation does not support that the enrollee in this case requires services at the LTACH that are not 
available at the acute care hospital where he is currently receiving care. There are no required medical services 
identified that are available at the LTACH, that are not available at the current health care setting being offered 
by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an office visit provided by an out-of-
network provider on July 1, 2020. 
 
You asked the Plan to waive the coinsurance for an office visit. You say that you called and was told that you 
were told that this provider was in-network. The Plan denied your request. The Plan says the correct 
coinsurance 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 50% 
coinsurance for physician/practitioner services/out-of-network.  
 
You have been asked to pay a 50% coinsurance of the allowed amount for an office visit. The total allowed 
amount is $214.38. The total amount you are being asked to pay is $107.19 ($214.38 x 50% = $107.19). An 
office visit falls within the physician/practitioner services/out-of-network 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 coinsurance for an office visit provided by an out-of-network provider on July 1, 
2020.  
 
We note your complaint about being told that this provider was in-network. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and 
does not require transfer to LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee 
still requires acute hospital level of care services and is receiving appropriate care at the present acute care 
hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital 
where she is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long-term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for transluminal balloon angioplasty (37248) provided June 26, 2020. 
 
You asked the Plan to pay for the transluminal balloon angioplasty. You say that all procedure codes billed are 
separately reimbursable per CCI edits. Please reprocess the claim to pay on all codes billed. The Plan denied 
your request. The Plan says the requested service code is not substantiated by the clinical documentation in the 
medical records submitted for review 
 
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 37248 is transluminal balloon angioplasty (except 
dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation 
necessary to perform the angioplasty within the same vein; initial vein. 
 
We find that CPT code 37248 is not supported in the medical record. Specifically, the narrative of the operative 
report did not include documentation of a transluminal balloon angioplasty (except dialysis circuit), by open or 
percutaneous approach, including all imaging and radiological supervision and interpretation necessary to 
perform the angioplasty within the same vein, for the initial vein. Based on this information, we decided that 
Medicare rules for coverage of the transluminal balloon angioplasty have not been met. Therefore, we decided 
that the Plan does not have to pay for transluminal balloon angioplasty (37248) provided June 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is on a ventilator and needs 
more time. The Plan denied your request. The Plan says the enrollee's medical needs are being met in the 
current acute setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician 
reviewer found LTACHs are certified as acute care hospitals, and in general, LTACHs do not provide clinical 
services that are materially different than those of short term acute care hospitals. In this case, ongoing care 
needs include oxygen supplementation and intermittent CPAP support, tracheostomy care, neurologic 
monitoring, intravenous antibiotics, surveillance laboratory studies, tube feeding, and therapy services. The 
documentation does not support that the enrollee in this case requires services at the LTACH that are not 
available at the acute care hospital where he is currently receiving care. There are no required medical services 
identified that are available at the LTACH, that are not available at the current health care setting being offered 
by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the medical records provided support the need for the 
requested drug. The Plan denied your request. The Plan says records do not show that the enrollee has tried or 
cannot use zoledronic acid. 
 
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 Prolia. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the enrollee has osteoporosis 
documented on a DEXA bone density scan with an 8x increased risk. The Plan requires a trial of the drug 
zoledronic acid before they will approve the requested drug. The records do not show that the enrollee has tried 
and failed the required drug. The records do not show that the required drug would likely be less effective 
and/or likely have adverse effects for the enrollee. Therefore, the requested drug is not considered medically 
reasonable or necessary at this point in 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient admission during kidney surgery for the enrollee. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan 
denied your request. The Plan says the plan can approve outpatient or ambulatory level of care. 
 
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 documentation outlines a plan for diagnostic laparoscopy, lysis of adhesions, and 
revision of catheterizale channel.  Documentation does not outline concerns for patient instability of increased 
risks related to the procedure. The requested surgery is not on the Medicare inpatient only list. There is no 
discussion outlined by the provider indication rationale for inpatient hospital care. Without the support of the 
documentation, medical necessity cannot be determined. 
 
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 inpatient admission during kidney surgery for the enrollee.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sleep study services (CPT 95810) provided to the enrollee on 
August 31, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says a polysomnography service should be reported within one year of a comprehensive sleep 
evaluation. 
 
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 95810 is "Polysomnography; age 6 years or older, sleep 
staging with 4 or more additional parameters of sleep, attended by a technologist." 
 
We asked our coding 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 reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found per 
Medicare a face-to-face Evaluation and Management visit with the referring physician before a sleep study is 
performed. The documentation submitted does not include a claim for an Evaluation and Management code 
prior to sleep study performed on August 31, 2020. CMS finalized a new requirement for a face-to-face 
encounter prior to ordering of certain durable medical equipment (DME) including CPAP/BIPAP effective July 
1, 2013. The rule specifies that the face-to-face encounter must occur within 6 months prior to the written order 
for new DME.  The face-to-face encounter may be performed by a physician, PA, NP or CNS.   However, if 
the encounter is performed by a non-physician practitioner, a physician must sign or cosign the portion of the 
patient?s medical record in which the encounter was documented, confirming that the encounter occurred.  A 
new code, G0454, will be implemented on July 1 to compensate the physician who documents encounters 
provided by a PA, NP or CNS. You can find this documentation AASM American Academy of Sleep 
Medicine. 
 
We looked at this coder'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 sleep study services (CPT 95810) provided to the enrollee on August 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cataract removal with the insertion of a intraocular lens 
prosthesis (66984) provided on August 5, 2020. 
 
You asked the Plan to pay for cataract removal with the insertion of a intraocular lens prosthesis. You say that 
this was billed correctly. The Plan denied your request. The Plan says this is not supported. 
 
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 find that CPT code 66984 is not supported in the medical record. Specifically, medical records have not 
been submitted for this service. Without this information, this code cannot be verified. Based on this 
information, we decided that Medicare rules for coverage of cataract removal with the insertion of a intraocular 
lens prosthesis have not been met. Therefore, we decided that the Plan does not have to pay for cataract 
removal with the insertion of a intraocular lens prosthesis (66984) provided on August 5, 2020.