Persius/hicric huggingface dataset:
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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found records do not document the need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. The enrollee is walking 
household distances with a rolling walker with contact guard to minimum assistance and was contact guard to 
minimum assist for transfers. The enrollee does not require the services on an inpatient basis, only in a skilled 
nursing facility setting. Continued care in the acute inpatient rehabilitation facility is appropriate until the 
patient is stable to transfer to a lower level of care such as home with home health 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 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 pre-approve occipital nerve blocks for the enrollee.
You asked the Plan to pre-approve the blocks. You say that this is needed to improve quality of life. The Plan denied your request. The Plan says there are only small and low-quality studies available for this request.
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 blocks. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the current literature has not demonstrated that the proposed therapy is effective in the management/prevention of chronic migraine headaches. Additionally, the enrollee is noted to have already undergone this procedure in the past without appreciable clinical improvement. 
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 blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve occipital nerve blocks for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gemtesa.
You asked the Plan to pre-approve Gemtesa. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Part B plan.
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 pre-approve Gemtesa.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71271 billed for date of service January 19, 
2022. 
 You asked the Plan to pay for procedure code 71271. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 71271 is bundled into payment for 
code 71275. 
 
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, we have confirmed that code 71271 
is a column II code to column I code 71275. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 71271 billed for date of service January 19, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 
15, 2021. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date. 
The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496.  
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 15, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on August 16, 
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 does not meet the coverage requirements. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the pre-surgical note, operative report, and intraoperative anesthesiology record were not available in the 
records submitted. The pre-anesthetic evaluation was included; however, no documentation of the 
intraoperative anesthesia care/intraoperative monitoring were provided. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for anesthesia services provided to the enrollee on August 16, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from October 4, 2021, to October 7, 2021.
You asked the Plan to pay for the services. You say that The Plan denied your request. The Plan says the services received were custodial in nature and not required daily.
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 pay for the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided, there is no documentation that the patient required skilled nursing or skilled therapy services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse or qualified therapist were not required to safely and effectively provide medically necessary and reasonable treatment from 10/04/2021 through 10/07/2021. The records did not document the administration of intravenous medications or need for new tube feeding or ostomy care or daily complex wound care. Daily skilled services were not required. Although the records document the patient was very limited functionally, provided records do not document any improvement in the patient's functional status despite daily skilled therapy services to necessitate any further daily inpatient skilled therapy services. The enrollee did not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the nursing facility appear custodial in this case from 10/04/2021 through 10/07/2021. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from October 4, 2021, to October 7, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 11, 2021. 
 
You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says the member 
was covered under Hospice on this date of service. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on August 5, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on August 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the hospital bed provided from January 4, 2022, to February 4, 2022.
You asked the Plan to waive the coinsurance for the hospital bed. You say that you are paying extra money and can't afford to. The Plan denied your request. The Plan says the coinsurance was 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 20% coinsurance for durable medical equipment, oxygen/ oxygen equipment and related supplies.
You have been asked to pay $60.70 for the hospital bed (allowed amount = $303.52 x 20%). The hospital bed falls within the "Durable medical equipment (DME) and related 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 coinsurance for the hospital bed provided from January 4, 2022, to February 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT) for the 
treatment of non-small cell lung cancer (NSCLC) 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 the records do not show detailed notes of a recent doctor consult, the number and type of 
treatments needed, results of other testing, or stage/type of cancer. 
 
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 there is no consultation note from a radiation oncologist and the clinical records that were provided 
mention a PET/CT scan being ordered for completeness of staging for which no information is provided. There 
is no evidence of a work-up to rule out nodal or distant metastases. 
 
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 stereotactic body radiation therapy (SBRT) for the treatment of non-small cell lung cancer 
(NSCLC) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on December 14, 2021. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says this provider 
opted out of Medicare effective January 1, 2017. As a member of the Plan for services to be covered, the 
providers must participate with Original Medicare whether they are in-network or out-of-network to receive 
payment from the Plan. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
physician's services provided on December 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the brain stem provided on February 28, 2022.
You asked the Plan to waive the copayment for the MRI. You say that the imaging was incorrectly billed as out-of-network. 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 $125 copayment per day for diagnostic radiology services, such as MRI's. 
You have been asked to pay a $125 copayment for the MRI. Please note that this is the in-network rate charged. The MRI falls 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 a magnetic resonance imaging (MRI) of the brain stem provided on February 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (70450) provided on February 15, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the services (70450) provided on February 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide additional routine transportation mileage.
You asked the Plan to provide additional mileage. You say that this transportation is necessary. The Plan denied your request. The Plan says the requested location is more than 50 miles away. You are covered for up to 48 one-way trips of up to 50 miles per year.
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 Plan's coverage rules apply in this case. The Plan covers routine transportation to Plan-approved locations within 50 miles of driving distance.
We looked at your request, the records in the case file, and the rules. The requested location is greater than 50 miles from the address on file with the Plan. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to provide additional routine transportation mileage.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lens fitting you had on December 22, 2021. 
 
You asked the Plan to pay for the contact lens fitting. The Plan denied your request. The Plan says this is not a 
covered benefit.  
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Neither Medicare 
nor the Plan covers a contact lens fitting as part of a routine eye exam. Therefore, we decided that the Plan does 
not have to pay for the contact lens fitting you had on December 22, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extracorporeal photopheresis provided on 
December 29, 2021. 
 
You asked the Plan to pay for extracorporeal photopheresis. You say that extracorporeal photopheresis is 
medically necessary. The Plan denied your request. The Plan says there was no documentation of lung allograft 
transplantation. 
 
The Plan follows Medicare rules. 
 
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 extracorporeal photopheresis. Our reviewer 
says that extracorporeal photopheresis is not medically necessary. Our physician reviewer found that the 
reviewed documentation indicates that the enrollee has at least a three-year history and treatment for 
Castlemans Disease, a disorder which leads to proliferation of cells in the lymphatic system. She developed 
dyspnea and airway obstruction consistent with Bronchiolitis Obliterans. She has failed inhalers, Cytoxan 
treatment, and oral cyclosporine. Scans have shown disease progression. She has been on apheresis treatment 
since 2018 which has resulted in ending supplemental oxygen and hospitalizations. In this case, the 
Extracorporeal Photopheresis does not meet the Medicare NCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of extracorporeal photopheresis have not been met. Therefore, we decided that the 
Plan does not have to pay for extracorporeal photopheresis provided on December 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service February 
12, 2022. 
 You asked the Plan to pay for procedure code 70450-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 70450-26 is bundled into 
payment for code 70496. 
 
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, we have confirmed that code 
70450-26 is a column II code to column I code 70496. This claim has not been billed with an appropriate 
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service 
February 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services you received on November 24, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the services you received on November 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for fundus photography of the eyes performed 
on December 20, 2021. 
 
You asked the Plan to waive the copayment for the fundus photography. You say that this should be included 
with the routine exam. 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 $40 
copayment for each exam to diagnose and treat diseases of the eye.  
 
You have been asked to pay a $40 copayment for the fundus photography. Please note that this was an 
additional test provided, and there was no charge for the routine exam. The fundus photography falls within the Vision Care 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 fundus photography of the 
eyes performed on December 20, 2021.