Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92014) and refraction (92015) provided on 
November 3, 2021. 
 
You asked the Plan to pay for the eye exam and refraction. You say that you would like reconsideration 
because this was your routine eye exam, and this should be covered. The Plan denied your request. The Plan 
says these services are not covered when provided out-of-network. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan does not cover these services when they are rendered by an out-of-network provider. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the eye exam and refraction have not been met. Specifically, the record shows that these services 
were rendered by an out-of-network provider. The Plan does not cover routine eye services when they are 
provided out-of-network. Therefore, we decided that the Plan does not have to pay for the eye exam (92014) 
and refraction (92015) provided on November 3, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from August 22, 2021, 
to September 23, 2021. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says Skilled 
Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 The file shows that the enrollee received 100 days of SNF care during the benefit period from January 7, 2021, 
to August 21, 2021. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for the skilled nursing services provided from August 22, 2021, to September 
23, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete abdominal ultrasound (76700) provided on 
October 15, 2021. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93976 and 76700. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed as required by Medicare coding regulations. 
 
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 76700 
is a column II code to column I code 93976. 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 complete abdominal ultrasound (76700) provided on October 
15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urine PCR panel testing (CPT code(s): 87798, 87482, 
87799) provided on November 17, 2021. 
 
You asked the Plan to pay for the Urine PCR panel testing. You say that the tests were medically necessary. 
The Plan denied your request. The Plan says the PCR testing is considered unproven and not medically 
necessary. 
 
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 Urine PCR panel testing. Our physician 
reviewer found there is no documentation that meets the requirements listed in the NCD: Urine Culture, 
Bacterial (190.12) for Medicare coverage. A urine culture was not performed in this case; a urine polymerase 
chain reaction panel was performed. A urine culture and sensitivity would be the standard test to perform for a 
diagnosis of urinary tract infection, site not specified. Provided records do not indicate why a urine polymerase 
chain reaction panel was requested or required in this case as opposed to a urine culture and sensitivity. 
 
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 Urine PCR panel testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the Urine PCR panel testing (CPT code(s): 87798, 87482, 87799) provided on 
November 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you are medically stable and do not need physical medicine and rehabilitation 
(PM&R) physician close supervision three (3) times per week (at a minimum) for the ongoing management of 
any active or acute exacerbations of chronic medical conditions. No acute rehabilitation nursing needs 
identified or documented in the record. You do not need intensive therapies, consisting of at least 3 hours of 
therapy per day at least five (5) days per week with multidisciplinary approach to daily therapy in an IRF. At the current level of function, your rehabilitation can be safely provided at a lower intensity and alternate setting 
such as in an in-home setting. IRF admission is not medically necessary based on medical stability and lack of 
medical complexity and lack of acute rehabilitation nursing needs and independent functional status does not 
require IRF admission. Document does not support the necessity for admission to an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient care provided from October 16, 2021, to 
October 19, 2021. 
 
You asked the Plan to pay for the inpatient care. You say that the enrollee was discharged from hospice on 
October 15, 2021. You say that the enrollee was not readmitted to hospice until October 19, 2021. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 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 October 15, 2021. The services in question were provided 
before the end of that month. Additionally, the record shows that the enrollee re-enrolled in hospice on October 
19, 2021. Therefore, we decided that the Plan does not have to pay for the inpatient care provided from October 
16, 2021, to October 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Next Generation Sequencing (CPT code 81455). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not necessary. 
 
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 physician reviewer 
found additional treatment options are being considered. Next Generation Sequencing (genetic testing) was 
requested. However, this test is not Food and Drug Administration (FDA) approved for this patient's condition 
and insufficient high-quality evidence is available to clearly show improved outcomes directly related to this 
test. Therefore, the provided records do not meet NCD Medicare requirements for coverage. 
 
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 the Next Generation Sequencing (CPT code 81455).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aduhelm (Aducanumab). 
 
You asked the Plan to pre-approve Aduhelm. You say that this is medically reasonable and necessary for your 
condition. The Plan denied your request. The Plan says the criteria for coverage have not been met as it is not 
clear Alzheimer's disease is causing enrollee's memory problems. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Aduhelm. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the documentation 
does not support that Aduhelm is medically reasonable and necessary for the enrollee in this case as the clinical 
documentation and the magnetic resonance imaging scan of the brain both suggest a mixed etiology for the 
enrollee's symptoms. In addition, the documentation does not support that Aduhelm is reasonably expected to 
be at least as beneficial as existing and appropriate and available medically appropriate alternatives for this 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aduhelm (Aducanumab).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the skilled nursing facility (SNF) services 
provided from October 1, 2021, to October 22, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to waive the coinsurance for the SNF services. You say that the enrollee tested positive for 
COVID-19, and it was your understanding that the enrollee would not be responsible for the cost share amount 
charges on the claim. The Plan denied your request. The Plan says the coinsurance amount that the enrollee is 
being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a 40% coinsurance per day for days 1 to 100 for out-of-network Skilled Nursing Facility (SNF) care.  
 The enrollee has been asked to pay a 40% coinsurance per day for out-of-network for the SNF services. The 
SNF services fall within the Skilled Nursing Facility (SNF) care benefit category. This means that the enrollee 
has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the coinsurance for the skilled nursing facility (SNF) services provided from October 1, 2021, to 
October 22, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the mental health services to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The 
Plan denied your request. The Plan says there is no gap issue and there are in-network providers available who 
can supply the requested service. 
 
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 mental health services to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 2 sensor (CPT code K0553). 
 
You asked the Plan to pre-approve the sensor. You say that the sensor is necessary. The Plan denied your 
request. The Plan says the sensor is not necessary. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
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 sensor. Our physician reviewer 
found you are not using insulin and hence, does not meet the criteria for CGM use given here- being on 
multiple daily doses of insulin (MDI) with frequent adjusts in insulin doses based on blood glucose (BG) level. 
 
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 sensor have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Freestyle Libre 2 sensor (CPT code K0553).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the WATS 3D biopsy provided on October 21, 2021. 
 
You asked the Plan to pay for WATS 3D biopsy. The Plan denied your request. The Plan says the WATS 3D 
biopsy is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for WATS 3D biopsy. Our reviewer says that 
the requested WATS 3D biopsy not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the review indicates that requested WATS 3D biopsy does not meet Medicare rules 
because a review of the medical literature and clinical guidelines does not support the clinical utility of this testing, including computer-assisted immunohistochemistry, to predict cancer. The review has determined that 
the WATS 3D biopsy at issue in this case is not medically reasonable or 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 WATS 3D biopsy have not been met. Therefore, we decided that the Plan does 
not have to pay for WATS 3D biopsy provided on October 21, 2021.
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 these services are medically necessary. 
The Plan denied your request. The Plan says that you are receiving appropriate care in the acute care hospital. 
 
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. You appear 
to have been improving but are currently requiring short-term additional acute care services that can be safely 
administered at the current facility until you are more stable again. You do not require services at the LTACH 
that are not already available at the current facility. There are no services at the LTACH that you require that 
are not already available and covered at the current facility. Our physician reviewer found that your 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.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on July 7, 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 the provider did not bill as required by Medicare coding regulations. 
 
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 70546 is a column II code to column I code 70553. 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 imaging services provided to the enrollee on July 7, 2021.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve the PET with concurrently acquired CT for attenuation correction 
and anatomical localization imaging; skull base to mid-thigh (CPT code 78815). 
 
You asked the Plan to pre-approve the PET scan. You say that the service is necessary. The Plan denied your 
request. The Plan says that a PET scan for initial staging for prostate 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 the PET scan. Our physician reviewer 
found Prostate-specific membrane antigen (PSMA) PET scan is supported by the National Comprehensive 
Cancer Network (NCCN) Guidelines as an alternative to bone scan for localized prostate cancer. This enrollee 
has a suspicious bone scan for metastases and a PSMA PET scan can offer alternative imaging that will help 
define if they have metastatic disease. The service is 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 the PET scan have been met. Therefore, we decided that the Plan has to pre-
approve the PET with concurrently acquired CT for attenuation correction and anatomical localization imaging; 
skull base to mid-thigh (CPT code 78815).  
 
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 pre-approve platelet rich plasma injections. 
 
You asked the Plan to pre-approve platelet rich plasma injections. You say that this is medically necessary for 
your condition. The Plan denied your request. The Plan says this procedure is not covered for your condition. 
 
The Plan must follow Medicare rules. Medicare rules say that the current evidence is insufficient to determine 
the effects of platelet rich plasma injections on health outcomes for osteoarthritis. 
 
We looked at the file and Medicare rules. In this case, the procedure is considered experimental/investigational 
for treating your condition of osteoarthritis. Based on this information, we decided that Medicare rules for 
coverage of platelet rich plasma injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve platelet rich plasma injections.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-routine transportation trips. 
 
You asked the Plan to pre-approve additional non-routine transportation trips. You say that the trips are 
necessary. The Plan denied your request. The Plan says the plan only allows 60 non-emergency trips. 
 
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.  
 
We looked at your request, the records in the case file, and the rules. Your 2022 EOC states that they cover up 
to sixty (60) one-way trips are covered each year (limited to ground transportation only). Therefore, additional trips are not covered. Therefore, we decided that the Plan does not have to pre-approve additional non-routine 
transportation trips.