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

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of abdomen and 
pelvis to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a CT scan. The Plan denied your request. The Plan says the services have 
been requested by an out-of-network provider. 
 
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 
a computed tomography (CT) scan of abdomen and pelvis to be provided by an out-of-network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 2, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services are covered and this claim should be 
paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on November 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bilateral facet joint injections (64493) provided on March 29, 
2022. 
 
You asked the Plan to pay for bilateral facet joint injections. You say that the injections were medically 
necessary. The Plan denied your request. The Plan says the injections did not meet criteria. 
 
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 bilateral facet joint injections. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is inadequate documentation that the facet joint injections provided 
on 03/29/2022 at issue in this case meet Medicare criteria for medically reasonable and necessary per Social 
Security Act, Section 1862(a)1(A). Provided records do not document failure of three months of noninvasive 
conservative management for the enrollee's 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 bilateral facet joint injections have not been met. Therefore, we decided that the 
Plan does not have to pay for bilateral facet joint injections (64493) provided on March 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) of the head or brain without 
contrast, followed by contrast material and further sections (70470) and CT of the head or brain without 
contrast (70450) provided on January 2, 2022. 
 
You asked the Plan to pay for CT scans billed with codes 70470 and 70450. 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 the billed services. These services were 
not billed appropriately 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 70470 
is a column II code to column I code 70496. This service has not been billed with an appropriate modifier to 
bypass the edit. In addition, we have confirmed that code 70450 is a column II code to column I code 70470 
with a modifier indicator of 0, which means that the column II code is not payable. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for computed tomography (CT) of the head or brain without contrast, followed by contrast material and 
further sections (70470) and CT of the head or brain without contrast (70450) provided on January 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Taltz. 
 
You asked the Plan to pre-approve Taltz. The Plan denied your request. The Plan says Taltz is on the self-
administered drug list and is excluded from coverage under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Taltz.  
 
Benefits for Taltz 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a primary care (PCP) telehealth visit 
provided on February 24, 2022. 
 
You asked the Plan to waive the copayment for the PCP telehealth visit. You say that the visit was only for a 
medication. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for each PCP visit, including telehealth services.  
 
The file shows that the Plan reprocessed the claim to apply the correct copayment for a PCP visit. Therefore, 
you have been asked to pay a $10 copayment for the PCP telehealth visit. The PCP 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 primary care (PCP) telehealth visit provided on February 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services (90832) provided to the enrollee 
on December 28, 2021. 
 
You asked the Plan to pay for these services. You say that the services provided were medically necessary. The 
Plan denied your request. The Plan says that there was no documented contact with the attending/primary care 
physician. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP must document, in the patient's medical 
record, the date the patient consented or declined consent to consultations, the date of consultation, or, if 
attempts to consult did not succeed, that date and manner of notification to the physician.  
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy services have not been met. Specifically, the record does not include documentation 
of a consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare 
rules. Therefore, we decided that the Plan does not have to pay for the psychotherapy services (90832) 
provided to the enrollee on December 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac risk assessment genetic screening testing coded 
as 81407, 81479, 81286, 81408, 81404 provided November 1, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the services in question were clearly 
medically necessary as evidenced by the enclosed requisition from the enrollee's treating physician. The Plan 
denied your request. The Plan says the records do not support the coverage criteria and the services are not 
covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules explicitly say that screening tests, with the exception of the few tests listed 
in the Medicare rules section, are not covered. 
 
We looked at the file, and Medicare rules. The records show that the Plan was unable to verify with the 
provider's office that the doctor wrote an order for the enrollee to undergo cardiovascular genetic testing. 
Outreach to the enrollee also verified that the enrollee also did not know who the ordering provider was. 
Genetic cardiovascular screening testing does not meet the definition of cardiovascular disease screening as 
outlined by CFR 410.17. The documentation does not indicate how the test will assist in managing the 
enrollee's condition. Based on this information, we decided that Medicare rules for coverage of the laboratory 
service have not been met. Therefore, we decided that the Plan does not have to pay for the cardiac risk 
assessment genetic screening testing coded as 81407, 81479, 81286, 81408, 81404 provided November 1, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthopedic surgeon services to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve orthopedic surgeon services. You say that you are appealing the denial to 
see an out-of-network surgeon. The Plan denied your request. The Plan says the service is not medically 
necessary. The alternative services include being seen by an in-network provider. 
 
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 
orthopedic surgeon services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from September 9, 2020, through 
October 3, 2021, at DRG 189. 
 
You asked the Plan to pay for inpatient services at DRG 189. You say that services were provided in good 
faith, and you were not paid the amount you were expected. The Plan denied your request. The Plan says the 
principal diagnosis code J96.0 was removed which resulted in a DRG change from 189 to 948. 
 
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 with principal diagnosis code J96.0, defined as acute respiratory 
failure with hypoxia. 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 inpatient services at DRG 
189. Our reviewer says that the documentation does not support principal diagnosis code J96.0. Our physician 
reviewer found the treatment plan included oxygen adjustment protocol, a pulmonary consultation, 
bronchodilator medication, cough suppressant medication and pulmonary hygiene. The admission history and 
physical examination report documents that the enrollee denied dyspnea and chest pain symptoms.  
 
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 services provided from September 9, 2020, through October 3, 2021, at DRG 189.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pembrolizumab (J9271). 
 
You asked the Plan to pre-approve Pembrolizumab. You say that you feel it is in the enrollee's best interest to 
resume Immunotherapy with Pembrolizumab. The Plan denied your request. The Plan says Pembrolizumab is 
not indicated for use in treating the lung cancer after 24 months of treatment. 
 
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 Pembrolizumab. Our reviewer says that 
Pembrolizumab is not reasonable and necessary. Our physician reviewer found the Food and Drug 
Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare 
approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the 
enrollee's clinical situation. Our reviewer found that no literature from Medicare approved cancer journals were 
submitted for review. The elements of the coverage criteria are not satisfied. Our physician reviewer also found 
that the requested service cannot be recommended. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Pembrolizumab have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Pembrolizumab (J9271).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound care services on January 14, 2022 to 
February 4, 2022. 
 
You asked the Plan to waive the copayment for wound care services. You say that you would like to appeal the 
cost share. The Plan denied your request. The Plan says the cost share applied 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 $225 copayment for wound care services.  
 
The enrollee has been asked to pay a $225 copayment for wound care services. Wound care services falls 
within the Outpatient hospital services 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 
copayment for wound care services on January 14, 2022 to February 4, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Arformoterol Tartrate (J7605). 
 
You asked the Plan to pre-approve Arformoterol Tartrate. The Plan denied your request. The Plan says the 
enrollee is using Stiolto. The Plan also says that the use of more than one of these drugs at the same time is not 
reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Arformoterol Tartrate. Our reviewer 
says that Arformoterol Tartrate is not reasonable and necessary. Our physician reviewer found Arformoterol 
Tartrate (J7605) is Food and Drug Administration-approved for chronic obstructive pulmonary disease but its 
use in combination with another long-acting beta-2 adrenergic agonist is not supported in the Medicare-
approved major drug compendia. Our reviewer also found that the combination of Arformoterol Tartrate with 
Stiolto is not supported by one of the major drug compendia or by clinical research that appears in a Centers for 
Medicare & Medicaid Services 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 Arformoterol Tartrate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Arformoterol Tartrate (J7605).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) for the right hand provided on 
March 3, 2022. 
 
You asked the Plan to pay for a wrist-hand orthosis. You say that the item at issue was a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in 
the enrollees medical record adequately supports the medical necessity for the item. 
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The available medical documentation does not discuss the item at issue. The record shows that the 
Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that 
the Plan does not have to pay for a wrist-hand orthosis (L3916) for the right hand provided on March 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 14, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services are covered and this claim should be 
paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on December 14, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for an inpatient psychiatric admission provided by an out-of-network 
provider on August 22, 2021, to September 15, 2021. 
 
You asked the Plan to pay for inpatient psychiatric hospital services. You say that these services were 
medically necessary. The Plan denied your request. The Plan says that the criteria for an inpatient psychiatric 
admission has not been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. Our 
reviewer says that the criteria for an inpatient psychiatric admission has been met. Our physician reviewer 
found the enrollee could not have been treated in a lesser restrictive setting as although he was not showing any 
suicidal or homicidal ideation, auditory or visual hallucinations this patient did continue to require active 
treatment with medication adjustment and mood symptoms. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pay for an inpatient psychiatric admission provided by an out-of-network provider on 
August 22, 2021, to September 15, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shower chair provided from October 12, 2021, from 
October 13, 2021. 
 
You asked the Plan to pay for a shower chair. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pay for a shower chair provided from October 12, 
2021, from October 13, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical, respiratory, speech, nutrition therapy, and 
continued care to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the physical, respiratory, speech, nutrition therapy, and continued care. The 
Plan denied your request. The Plan says the requested services are routine, and can be safely rendered at a 
contracted facility. 
 
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 
physical, respiratory, speech, nutrition therapy, and continued care to be provided by an out-of-network (OON) 
provider.