Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the exam (99387) you had on May 17, 2021.
You asked the Plan to pay for the exam. You say that this should be covered. The Plan denied your request.
The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "N" under the Physician Fee
Schedule indicates that the code in question is not covered.
We looked at the file and Medicare rules. In this case, you saw a non-contract provider who billed the
requested exam with code 99387. Code 99387 is assigned a status indicator of "N" under the physician fee
schedule, which means that this is a non-covered service. Based on this information, we decided that Medicare
rules for coverage of the exam have not been met. Therefore, we decided that the Plan does not have to pay for
the exam (99387) you had on May 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine provided on December 16, 2020 and February 17, 2021.
You asked the Plan to pay for this vaccine under Medicare Part B. You say that this vaccine should be covered by the Plan. The Plan denied your request. The Plan says this vaccine is covered under the Part D benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide this vaccine under Medicare Part B. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to this vaccine under Medicare Part B. Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided on December 16, 2020 and February 17, 2021.
Benefits for this vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 9 home health skilled nursing visits.
You asked the Plan to pre-approve 9 home health skilled nursing visits. 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 home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 9 home health skilled nursing visits.
Our reviewer says that the services are not medically necessary. Our physician reviewer found based on the
medical records provided there is no documentation that skilled nursing services are required to effectively
provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a
maintenance program to maintain the enrollee's condition and/or prevent deterioration. The records do not
document any acutely unstable medical conditions, wounds or medication changes requiring the expertise of a
skilled nurse.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 9 home health skilled nursing visits have not been met. Therefore, we decided
that the Plan does not have to pre-approve 9 home health skilled nursing visits
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ophthalmology visit (92004) provided
June 29, 2021.
You asked the Plan to waive the copayment for the ophthalmology visit. You say that the copayment should be
waived. The Plan denied your request. The Plan says the correct copayment was applied.
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 specialist visits.
You have been asked to pay a $40 copayment for the ophthalmology visit. The ophthalmology visit falls within
the specialist 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 an ophthalmology
visit (92004) provided June 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says treatment for cancer of the small intestine would require progression of the tumor while on standard treatments and genetic abnormalities.
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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the requested drug is not FDA approved for the treatment of metastatic cholangiocarcinoma, supported by major drug compendia, or the medical literature. Approval is appropriate for MSI-High or dMMR tumors but here is no information provided that this is met. The service 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 the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the semi-private room provided on January
21, 2021 by a non-preferred provider.
You asked the Plan to waive the copayment for the semi-private room. You say that you feel you should not be
held liable for the copayment because you were not aware that this hospital was not in-network. The Plan
denied your request. The Plan says this claim was processed correctly with your non-preferred/in-network
inpatient hospital care benefits as listed in your 2021 EOC.
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 $440
copayment per day for day(s) 1 to 5 for Inpatient Hospital Care rendered by a non-preferred provider.
You have been asked to pay a $440 copayment per day for day(s) 1 to 5 for the semi-private room. The semiprivate
room falls within the Inpatient Hospital 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 the semi-private room provided on January 21, 2021 by a non-preferred provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency
transport (A0428) and ground mileage, per statute mile (A0425) provided March 17, 2021.
You asked the Plan to pay for the non-emergency ambulance services. You say that you would like the
transport covered. The Plan denied your request. The Plan says after reassessing the entire clinical situation,
information provided at the time of the appeal does not support medical necessity for ambulance transport.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same 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 the non-emergency ambulance services. Our
reviewer says that the non-emergency ambulance services were not medically necessary. Our physician
reviewer found that the documentation does not support that other means of transport (such as stretcher van,
wheelchair van) were contraindicated for this enrollee on March 17, 2021. The documentation does not support
that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully
equipped ambulance can provide for safe transport on March 17, 2021. The documentation does not support
that the ambulance transport on March 17, 2021. was medically reasonable and necessary for the enrollee as the
enrollee was stable for this non-emergent transport.
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 non-emergency ambulance services have not been met. Therefore, we
decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency
transport (A0428) and ground mileage, per statute mile (A0425) provided March 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient physician services provided on September 8,
2019.
You asked the Plan to pay for the inpatient physician services. You say that this claim was originally submitted
within the allowed timeframe. The Plan denied your request. The Plan says this claim was not submitted within
one calendar year of the date of service.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for the inpatient physician services was not filed until April 21, 2021. This
means that more than one calendar year from the date of service had passed before a claim was filed.
Therefore, we decided that the Plan does not have to pay for the inpatient physician services provided on
September 8, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the radiologic exam of the ankle (73610)
provided on April 15, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service provided.
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 $10 per
day for Medicare-covered x-rays.
You have been asked to pay a $10 copayment for the Medicare-covered x-ray provided. 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 the radiologic exam of the ankle (73610) provided on April 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services (27217, 27275, 27216) provided
October 16, 2019.
You asked the Plan to pay for the surgical services. You say that you would like this claim reprocessed for
medical necessity. The Plan denied your request. The Plan says this claim has been filed 1 year past the date of
service and is untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for the surgical services was not filed until May 21, 2021. This means that more
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that
the Plan does not have to pay for the surgical services (27217, 27275, 27216) provided October 16, 2019.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request.
The Plan says that rules for SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the
requested SNF care is medically reasonable and necessary. Our physician reviewer found you are a 93-year-old
male with a past medical history of hypertension and chronic kidney disease who presented to the acute
hospital on August 26, 2021, with hematuria, abdominal pain, acute kidney injury, urinary tract infection and
sepsis with atrial fibrillation with rapid ventricular response. While you do not require skilled nursing services,
you do require skilled therapy services. In addition, these skilled services are required on a daily basis. In
conclusion, based on the medical records provided you do require the services on an inpatient basis, in a skilled
nursing facility setting due to his documented decline in function compared to his level prior to hospitalization.
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 been met. The Plan must continue coverage for the SNF skilled
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing
facility (SNF) care.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided from May 12, 2020, to May
18, 2020.
You asked the Plan to pay for the inpatient hospital care. You say that DRG 868 is correct. The Plan denied
your request. The Plan says DRG 869 was more appropriate for the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
In this case, you billed the inpatient services provided with DRG 868. 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 inpatient hospital care. Our reviewer says that DRG 868 is not supported in
the records. Our physician reviewer found the enrollee presented with fever, weakness, diarrhea, decreased oral
intake, and ambulatory dysfunction. There was a recent history of tick bite. Labs were remarkable for
leukopenia, thrombocytopenia, initial sodium of 132, mild transaminitis, and negative COVID-19 test. Sodium
ranged from 132 to 141 during the stay. While it was a noted diagnosis in the records, hyponatremia was not
specifically managed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for inpatient hospital care provided from May 12, 2020, to May 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for group health education (99078), a hearing aid device (V5267) and a hearing aid repair (V5014) provided on July 29, 2019, to October 9, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for a group health education, hearing aid device and a hearing aid repair. You say that you disagree with the out-of-pocket expense as you were charged, and you paid $492. The Plan denied your request. The Plan says services should be received from network providers who are listed in the provider directory.
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 group health education (99078), a hearing aid device (V5267) and a hearing aid repair (V5014) provided on July 29, 2019, to October 9, 2020, by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator 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 there is no evidence of treatment for any of the required conditions.
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 the records show chronic low back pain. There is no documentation of adequate treatment measures.
More conservative measures are needed to treat back pain.
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 a spinal cord stimulator for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on October 23,
2020.
You asked the Plan to pay for this service. You say that this claim should have been paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.
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 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 physician services provided to the enrollee on
October 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (70450) provided on April 7, 2021.
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 70540
has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate
line item. 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 April 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular radiofrequency ablation.
You asked the Plan to pre-approve genicular radiofrequency ablation. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve genicular radiofrequency ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/investigational procedure. Therefore, the request is deemed 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 genicular radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular radiofrequency ablation.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of the breast
provided on December 2, 2020.
You asked the Plan to pay for the MRI. The Plan denied your request. The Plan says experimental services are
not covered.
The Plan follows Medicare rules. Medicare rules say that a breast MRI is covered for the indications
established in the applicable LCD.
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 MRI. Our reviewer says that the
requested breast MRI was not medically reasonable and necessary. Our physician reviewer found that the
enrollee does not meet the criteria established in the LCD.
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 MRI have not been met. Therefore, we decided that the Plan does not have
to pay for the magnetic resonance imaging (MRI) of the breast provided on December 2, 2020.