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

 
We decided that the Plan does not have to pay for infectious agent detection by nucleic acid with 12-25 target 
(87633) provided on September 24, 2021, through September 25, 2021. 
 You asked the Plan to pay for the 12-25 target respiratory panel.. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says multiplex PCR respiratory viral 
panels of 6 or more pathogens are non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that tests that include more than 5 viral pathogens are 
non-covered. 
 
In this case, the CPT Code Manual definition of code 87633 is infectious agent detection by nucleic acid (DNA 
or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza 
virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and 
multiplex amplified probe technique, multiple types or subtypes, 12-25 targets. 
 
We find that CPT code 87633 is not supported in the record. Specifically, CPT code 87633 represents 12-25 
targets. Multiplex PCR respiratory viral panels of 6 or more pathogens are non-covered. Based on this 
information, we decided that Medicare rules for coverage of the 12-25 target respiratory panel. have not been 
met. Therefore, we decided that the Plan does not have to pay for infectious agent detection by nucleic acid 
with 12-25 target (87633) provided on September 24, 2021, through September 25, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care to be provided by a 
network facility. 
 
You asked the Plan to pre-approve the SNF care. You say that the SNF care is medically necessary. The Plan 
denied your request. The Plan says authorization denied because the SNF care is not medically necessary and 
the enrollee's needs can be met a lower level of care such as home with home health, in residential care, or 
home with close follow-up with their doctor.  
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 the SNF care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found based on the documentation provided, 
the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. 
The enrollee does not have documented skilled therapy needs. The enrollee is ambulating more than 100 feet. 
Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the 
enrollees condition. The enrollees care needs, custodial and intermittent, can, as a practical matter, be 
provided at a lower level of care (ex. home, assisted living, long-term 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) care to be provided by a network facility.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that this drug is medically reasonable and necessary. The 
Plan denied your request. The Plan says this drug is not being prescribed for a medically accepted indication. 
 
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 Keytruda. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the requested use of 
Keytruda is not FDA-approved for the enrollees diagnosis of ovarian cancer PDL1+. In addition, the use of 
Keytruda is not supported by one of the major drug compendia or by clinical research that appears in a 
Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device placement surgery (22869). 
 
You asked the Plan to pre-approve the Vertiflex device placement surgery. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the service is experimental. 
 
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 Vertiflex device placement surgery. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this service is experimental, more research is needed to show its safety and 
efficacy. 
 
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 Vertiflex device placement surgery have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Vertiflex device placement surgery (22869).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are unable to walk and not being admitted to an 
IRF would jeopardize your ability to regain function. The Plan denied your request. The Plan says IRF is not 
medically necessary and clinical notes do not show that you require IRF care. 
 
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 that while you may benefit from physical therapy (PT), and occupational therapy 
(OT), your rehab needs can be addressed at a low intensity alternate setting such as in a skilled nursing facility 
(SNF). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says your need can be met 
at a lower level of care. 
 
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 physician reviewer found 
that you were admitted to the acute care hospital for colon resection with colostomy. Your hospital care was 
complicated by intestinal leak and anemia. Your medical problems are stable. The complexity of your nursing, 
medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided to the enrollee on July 8, 
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 there are no modifiers available for this edit. 
 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 99309 
is a column II code to column I code 90792. 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 skilled nursing services provided to the enrollee on July 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external upper limb tremor stimulator of the nerves 
of the wrist (K1018) and supplies (K1019). 
 
You asked the Plan to pre-approve an external upper limb tremor stimulator of the nerves of the wrist and 
supplies. You say that the items are medically necessary. The Plan denied your request. The Plan says the items 
are experimental. 
 
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 an external upper limb tremor 
stimulator of the nerves of the wrist and supplies. Our reviewer says that the requested items are not considered 
medically reasonable and necessary in this case. Our physician reviewer found there is no clinical 
recommendation that this device is used for the treatment of essential tremor.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an external upper limb tremor stimulator of the nerves of the wrist and supplies 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an external upper limb 
tremor stimulator of the nerves of the wrist (K1018) and supplies (K1019).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve the SNF care. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not medically necessary. 
 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 the SNF care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented 
skilled therapy or skilled nursing needs. 
 
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 SNF care have not been met. Specifically, medically necessary services can 
be obtained at a lower level of care. This means admission into a SNF is not medically necessary or reasonable. 
Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated abutments (D6056) and abutment-
supported crowns (D6060, D6058). 
 
You asked the Plan to pre-approve dental services. You say that these services are necessary. The Plan denied 
your request. The Plan says these services are not covered by your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
prefabricated abutments (D6056) and abutment-supported crowns (D6060, D6058).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve positron emission tomography (PET) and computed 
tomography (CT) scan services. 
 
You asked the Plan to pre-approve the PET/CT scan. You say that the requested imaging is medically 
necessary. The Plan denied your request. The Plan says the requested imaging is not needed to assess the 
enrollee's status after treatment, or due to a significant change in the enrollee's status that suggests his disease 
has spread or transformed. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
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 pre-approve the PET/CT scan. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the requested imaging is for 
patients with suspected metastasis who are candidates for initial definitive therap. Our physician reviewer 
found that the enrollee's initial therapy has already started, and the requested scan is no longer indicated. 
 
 
 
 
 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/CT scan have not been met. Therefore, we decided that the Plan does 
not have to pre-approve positron emission tomography (PET) and computed tomography (CT) scan services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on January 20, 
2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you went to the physician's office 
for your annual wellness visit and you should not have to pay a copayment for this service. The Plan denied 
your request. The Plan says you have been charged the correct copayment 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 an in-
network $5 copayment for each primary care provider visit or telehealth visit for Medicare-covered benefits.  
 
 
 
 
 You have been asked to pay a $5 copayment for an office visit. The office visit falls within the 
Physician/Practitioner services, including doctor's office visits benefit category. The records show this visit 
was a follow-up visit for certain medical conditions. 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 
an office visit provided on January 20, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve the SNF care. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not medically necessary. 
 
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 the SNF care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented 
skilled nursingor skilled therapy needs. 
 
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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a telehealth visit provided on January 6, 
2022. 
 
You asked the Plan to waive the copayment for a telehealth visit. You say that you feel that the phone 
consultation was not needed because you received the covid-19 test result via email. The Plan denied your 
request. The Plan says you have been charged the correct copayment 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 $15 
copayment for each covered telehealth visit or consultation in an outpatient location with your PCP or other 
primary care provider.  
 You have been asked to pay a $15 copayment for a telehealth visit. The telehealth visit falls within the 
Physician/Practitioner services, including doctor's office visits 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 telehealth visit provided on January 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical laparoscopy with tubal cautery (58670). 
 
You asked the Plan to pre-approve a laparoscopy with tubal cautery. You say that the requested procedure is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested procedure is not a 
covered benefit in the enrollee's clinical situation. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may be made only where sterilization is 
a necessary part of the treatment of an illness or injury. 
 
We looked at the file and Medicare rules. The available medical records indicate that the procedure at issue is 
requested for an indication of sterilization only. Based on this information, we decided that Medicare rules for 
coverage of a laparoscopy with tubal cautery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a surgical laparoscopy with tubal cautery (58670).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and the drainage of skin abscess provided on 
November 8, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and the drainage of skin abscess. You say that you have attached a 
printout from the Plan's website stating no prior authorization is needed for this service. The Plan denied your 
request. The Plan says the rendering provider is a non-participating provider and there is no referring provider 
involved in these services. The Plan also says that they did not authorize any services for the providers 
involved in this 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 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 and the drainage of skin abscess 
provided on November 8, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to reduce the copayment for a CT provided on November 2, 2021. 
 
You asked the Plan to reduce the copayment for a CT. You say that you paid $125 for a CT scan and now you 
have received a bill for an additional $150. The Plan denied your request. The Plan says that you have been 
charged the correct copayment amount. 
 
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 enrollees must pay a $125 copayment for Medicare-covered radiological 
diagnostic services, not including x-rays, performed in a physician's office or at a free-standing facility (such as 
a radiology center or medical clinic). 
 
The Plan says you must pay a $275 copayment for a CT. The only allowed amount on the claim is for the CT. 
Based on the Plan contract, however, you cannot be asked to pay more than a $125 copayment for a CT. 
Therefore, we decided that the Plan has to reduce the copayment for a CT provided on November 2, 2021.  
 
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.