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

 
We decided that the Plan does not have to pre-approve Monovisc. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria.  The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has right knee 
osteoarthritis. She has not tried and failed one of the Plan's required drugs, Euflexxa, Supartz FX, Durolane, or 
Gelsyn-3. The records do not show that the required drugs would be contraindicated or less effective; therefore, 
the Monovisc is not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Monovisc.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided by the EMS, on January 20, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that the ambulance was called against your will and you should not be held financially liable. The Plan denied your request. The Plan says based on Medicare guidelines, the ambulance non-transportation service (A0998) that you are requesting does not meet the requirements for approval.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.
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 ambulance response and treatment, no transport. Our reviewer says that ambulance response and treatment, no transport does not meet Medicare coverage criteria. Our physician reviewer found that the record indicates that you had a syncopal episode and emergency medical services (EMS) was activated by law enforcement. The record indicates that you were treated in place and declined transportation. The record does not indicate that transport did not occur as a result of community-wide EMS protocols due to the Coronavirus public health emergency. The elements of the coverage rule are not satisfied. The requested service cannot be recommended.
The ambulance company did not provide transport services on January 20, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on January 20, 2021.
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. 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. 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the telephone evaluation and management (E/M) service represented by 
code 99442 provided on May 20, 2021. 
 
You asked the Plan to pay for code 99442. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says that the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan denied payment for code 99442 provided on May 20, 2021, 
stating that the provider has performed the appealed service within the excluded 7-day period following the 
related E/M procedure 99204 rendered previously on May 13, 2021. However, the Plan has provided no 
medical records from the May 13, 2021 date of service to verify if the two visits were related. Therefore, we 
decided that the Plan has to pay for the telephone evaluation and management (E/M) service represented by 
code 99442 provided on May 20, 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308) 
rendered by the out-of-network (OON) provider on August 17, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the subsequent nursing facility care, per day (99308) rendered by the out-of-network 
(OON) provider on August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent observation care represented by code 99226 
provided on June 18, 2021. 
 You asked the Plan to pay for code 99226. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Payment for an initial observation care code is 
for all the care rendered by the ordering physician on the date the patient's observation services began. All 
other physicians who furnish consultations or additional evaluations or services while the patient is receiving 
hospital outpatient observation services must bill the appropriate outpatient service codes. 
 
We find that CPT code 99226 is not supported in the medical record for payment. Specifically, the record 
shows that another physician was already paid for the initial observation care (99220). The provider in this case 
should bill with the new or established office or other outpatient visit code as appropriate. Therefore, we 
decided that the Plan does not have to pay for the subsequent observation care represented by code 99226 
provided on June 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xgeva (J0897). 
 
You asked the Plan to pre-approve Xgeva. The Plan denied your request. The Plan says the information 
submitted does not meet the Plan's medical necessity guidelines for coverage. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria.  The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Xgeva. Our reviewer says that Xgeva 
(J0897) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the enrollee 
has not tried and failed the required drugs, Intravenous Pamidronate or Zoledronic Acid. Our reviewer also 
found that there is no indication that the Plan's required drugs would likely be less effective and/or likely have 
adverse effects for the 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 Xgeva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xgeva (J0897).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placements of implant bodies: endosteal 
implants (D6010) for tooth #'s 4, 5, 10, 12, and 13. 
 
You asked the Plan to pre-approve the endosteal implants. You say that you believe these implants are 
medically necessary. The Plan denied your request. The Plan says this request is not medically necessary.  
 
 The Plan also says that there is more than one missing tooth in the arch, and the documentation does not show 
that the enrollee has a failed history with a removable partial upper denture, nor any medical condition to 
preclude the use of a removable partial denture. 
 
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. The Plan covers the endosteal 
implants when the services are medically necessary and reasonable.  
 
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 endosteal implants. Our reviewer 
says that implant crowns replacing missing tooth #'s 4, 5, 10, 12, and 13 is not a covered expense. Our 
physician reviewer found an implant crown is covered where only one tooth is missing in an arch and being 
replaced. Our reviewer also found that no contraindication for a removable partial was indicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the endosteal implants have not been met. Therefore, we decided that the Plan 
does not have to pre-approve surgical placements of implant bodies: endosteal implants (D6010) for tooth #'s 4, 
5, 10, 12, and 13.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 13, 2021, 
to July 14, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this bill is too much for you to pay for 
one night in the hospital. The Plan denied your request. The Plan says the inpatient stay was not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found as your records show that you were stable and asymptomatic at the time of admission 
with negative workup, it was not expected that you would require hospital services that would likely cross 2 
midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from July 13, 2021, to July 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) 
rendered by the out-of-network (OON) provider on July 30, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the subsequent nursing facility care, per day (99309) rendered by the out-of-network 
(OON) provider on July 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing (0013M) provided on May 13, 2021. 
 
You asked the Plan to pay for code 0013M. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
  The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M for CxBladder are 
non-covered.  
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of code 0013M have not been met. Therefore, we decided that the 
Plan does not have to pay for the CxBladder testing (0013M) provided on May 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care provided from March 24, 2021, 
to March 25, 2021. 
 You asked the Plan to pay for the subsequent hospital care. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
Medicare guidelines say that ICD-10-CM has a coding convention that requires the underlying condition to be 
sequenced first, followed by the manifestation. In this case, F05 is a manifestation code and cannot be used as 
the primary or first-listed diagnosis code on the claim. Therefore, we decided that the Plan does not have to pay 
for the subsequent hospital care provided from March 24, 2021, to March 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Lipiflow procedure provided on February 10, 2021. 
 
You asked the Plan to pay for these services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says that these services are experimental and investigational because of 
insufficient evidence of their effectiveness. 
 
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 these services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. The record indicates that 
you have dry eye. The record indicates that you were aware that this was an uncovered service. The record 
provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the 
requested service. Our physician reviewer found that your condition does not meet criteria for coverage of 
these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the Lipiflow procedure provided on February 10, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99285) provided November 21, 
2020. 
 
You asked the Plan to pay for the emergency room services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 
 
 
 
 We looked at the file and Medicare rules. No medical records were provided to support the services billed. The 
plan requested additional records, and none were received. Based on this information, we decided that 
Medicare rules for coverage of the emergency room services have not been met. Therefore, we decided that the 
Plan does not have to pay for emergency room services (99285) provided November 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nerve conduction studies; 7-8 studies (95910) and the 
needle electromyography (95885 and 95886) provided on June 1, 2021. 
 
You asked the Plan to pay for codes 95910, 95885, and 95886. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 95910 is Nerve conduction studies; 7-8 studies. 
 
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 codes 95910, 95885, and 95886. Our reviewer says that the 
medical records do not support the billing of code 95910. Our reviewer found in this case 3 motor nerves were 
studied. Only one anti-sensory nerve was studied. Even then only 2-3 nerves were evaluated. This would 
represent 6 studies at the most as is below the definition of the minimal number of studies needed to be done 
for code 95910. 
 
In this case, we have also confirmed that codes 95885 and 95886 are add-on codes and as the primary 
procedure code, 95910, is not covered, codes 95885 and 95886 are not covered. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 95910, 95885, and 95886 have not been met. Therefore, we decided that 
the Plan does not have to pay for the nerve conduction studies; 7-8 studies (95910) and the needle 
electromyography (95885 and 95886) provided on June 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on February 26, 2021.
You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says an eye refraction is an exclusion using the Plan's medical coverage.
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.
We looked at the file, the Plan's rules and the Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on February 26, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services coded as 99053 provided on January 21, 
2021. 
 
You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says this service is not separately 
payable under Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99053 is service(s) provided between 10:00 PM and 8:00 
AM at 24-hour facility, in addition to basic service.  
We find that CPT code 99053 is not supported in the medical record. Specifically, CPT code 99053 has a status 
indicator of B meaning that payment for this service is always bundled into another procedure. Separate 
payment is not made for CPT code 99053. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for the medical services coded as 99053 provided on January 21, 2021.