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

We decided that the Plan does not have to pay for testing services provided to the enrollee on September 20, 2021.
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 this service is only billable by the facility.
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 the denied codes is: 
CPT 95938: Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs
CPT 95861: Needle electromyography; 2 extremities with or without related paraspinal areas 
CPT 95940: Continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List separately in addition to code for primary procedure) 
HCPCS A4215: Needle, sterile, any size, each 
HCPCS A4556: Electrodes, (e.g., apnea monitor), per pair 
We asked our coder 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 reviewer found if the mobile unit is serving an entity for which another Place of Service (POS) code already exists, providers should use the POS code for that entity; however, if the mobile unit is not serving an entity that could be described by an existing POS code, the providers are to use the Mobile Unit POS code 15. Medicare will apply the non-facility rate to payments for services designated as being furnished in POS code 15 and apply the appropriate facility or non-facility rate for the POS code designated when a code other than the mobile unit code is indicated. 
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 testing services provided to the enrollee on September 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an interlaminar/interspinous process 
stabilization/distraction device. 
 
You asked the Plan to pre-approve insertion of an interlaminar/interspinous process stabilization/distraction 
device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity 
has not been established. Therefore, coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve insertion of an interlaminar/interspinous 
process stabilization/distraction device. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found interspinous distraction devices 
remain experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of an interlaminar/interspinous process stabilization/distraction device 
have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an 
interlaminar/interspinous process stabilization/distraction device.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for neuropsychological testing administration 
and evaluation provided on January 26, 2022. 
 
You asked the Plan to waive the deductible for the neuropsychological testing. You say that you were not 
examined in January. The Plan denied your request. The Plan says the correct amount was applied to your 
deductible. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $500 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $500 deductible which applies to certain items and services. This cost 
sharing is a contractual obligation that had not been met at the time the neuropsychological testing was 
received on January 26, 2022. Therefore, we decided that the Plan does not have to waive the deductible for 
neuropsychological testing administration and evaluation provided on January 26, 2022.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare coverage criteria have been met. 
We looked at the file and Medicare rules. Specifically, medical records were not provided. Without this documentation, medical necessity is not able to be established. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for venipuncture provided on December 22, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for venipuncture. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 had network providers 
available who could have provided 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 venipuncture provided on December 22, 2021 by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on October 14, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the Plan does not have to pay for the lab services provided on October 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit for the evaluation and management of a new 
patient (99342) and the nail debridement (11721) rendered by the out-of-network (OON) provider on 
December 19, 2021. 
 
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 services were rendered by an out of 
network provider, without prior authorization. 
 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided 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 home visit for the evaluation and management of a new patient (99342) and 
the nail debridement (11721) rendered by the out-of-network (OON) provider on December 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hydrophilic soft contact lenses (V2523).
You asked the Plan to pre-approve hydrophilic soft contact lenses. You say that you would like these items reprocessed and approved for payment as you believed they were approved by the Plan. The Plan denied your request. The Plan says the documentation supports that these items were requested for a noncovered indication.
The Plan must follow Medicare rules. Medicare rules say that when hydrophilic soft contact lenses (V2520, V2521, V2522, V2523) are used as a corneal dressing, they are denied as noncovered because in this situation they do not meet the definition of a prosthetic device. 
We looked at the file and Medicare rules. In this case, the documentation confirms that hydrophilic soft contact lenses were being used as a corneal dressing, a noncovered indication. Based on this information, we decided that Medicare rules for coverage of hydrophilic soft contact lenses have not been met. Therefore, we decided that the Plan does not have to pre-approve hydrophilic soft contact lenses (V2523).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Drug Testing provided on January 14, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Drug Testing. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
 
 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 had network providers 
available who could have provided 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 Drug Testing provided on January 14, 2022 by an 
out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued SNF services.
You asked the Plan to pre-approve SNF. You say that you do not feel you are healthy enough to go home on your own. The Plan denied your request. The Plan says rules for SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the medical records do not document that you require services on an inpatient basis, only in a skilled nursing facility. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve extended SNF stay.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cyramza, Pembrolizumab, and Diphenhydramine.
You asked the Plan to pre-approve Cyramza, Pembrolizumab, and Diphenhydramine. You say that the use of this requested drug regimen is medically necessary for treatment of the enrollee's cancer. The Plan denied your request. The Plan says the requested drugs are not medically reasonable and 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 Cyramza, Pembrolizumab, and Diphenhydramine. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the record indicates that the enrollee has a diagnosis of stage IV adenocarcinoma of the lung. The Food and Drug Administration has not stated that the requested drugs regimen is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug regimen in the enrollee's clinical situation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Cyramza, Pembrolizumab, and Diphenhydramine have not been met. Therefore, we decided that the Plan does not have to pre-approve Cyramza, Pembrolizumab, and Diphenhydramine.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cardiovascular screening/risk assessment panel provided to 
the enrollee on August 24, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says no progress notes or office notes were submitted. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this testing is not currently sufficiently supported by high quality evidence for use in patients with 
similar clinical history. The patient already has a high risk of cardiovascular disease and standard guidelines for 
treatment and monitoring should be sufficient for this patient. There was insufficient support provided suggesting the cardiovascular genetic testing would significantly change the treatment for this patient or overall 
outcome. Therefore, this request for genetic testing will be considered not medically necessary at this time.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for a cardiovascular screening/risk assessment panel provided to the enrollee on August 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 19, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to appeal the denial of the claim. The 
Plan denied your request. The Plan says the provider is out-of-network and authorization is required prior to an 
out-of-network visit. 
 
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 had network providers 
available who could have provided 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 an office visit provided on January 19, 2022 by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation (D4921) and the unspecified
periodontal procedure (D4999) provided by a network provider on January 31, 2022.
You asked the Plan to pay for the gingival irrigation (D4921) and the unspecified periodontal procedure
(D4999). You say that the gingival irrigation and periodontal procedures are considered a deep cleaning which
is listed as a covered service. The Plan denied your request. The Plan says the services are not covered benefits.
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 gingival irrigation (D4921) and the unspecified periodontal procedure (D4999) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the gingival irrigation (D4921) and the unspecified periodontal procedure (D4999) provided by a network provider on January 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you have appointments 
to attend and would like additional rides. The Plan denied your request. The Plan says the requested services 
exceed your benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 20 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Libtayo (CPT code J9119). 
 
You asked the Plan to pre-approve the medication. You say that this medication is to treat recurrent squamous 
cell carcinoma and basal cell carcinoma of the skin, locally advanced. The Plan denied your request. The Plan 
says that the medication is not 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 the medication. Our physician reviewer 
found the requested use of Libtayo is FDA-approved for the enrollees diagnosis because the enrollee is non-
operable 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 medication have been met. Therefore, we decided that the Plan has to pre-
approve Libtayo (CPT code J9119).  
 
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve SNF services. You say that you need to be admitted to SNF for rehabilitation because you are being discharged from the hospital. The Plan denied your request. The Plan says rules for SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the medical records do not document that you require services on an inpatient basis, only in a skilled nursing facility. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the physical therapy services by an out-of-network provider.
You asked the Plan to pre-approve the physical therapy services. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that can provide the services.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the physical therapy services by an out-of-network provider.