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

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on December 
22, 2021. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you believe this bill is an error. 
The Plan denied your request. The Plan says the copayment 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). Your contract with the Plan clearly says that you must pay $250 
copayment for each Medicare-covered visit to an outpatient hospital facility. 
 
 
 
 
 
 
 
 You have been asked to pay $250 copayment for outpatient surgery. Outpatient surgery falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers 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 outpatient surgery provided 
on December 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging. 
 
You asked the Plan to pre-approve myocardial perfusion imaging. The Plan denied your request. The Plan says 
the enrollee does not meet coverage 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 myocardial perfusion imaging. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is insufficient documentation to support the medical necessity for the 
requested cardiac stress testing in this enrollees clinical management. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of myocardial perfusion imaging have not been met. Therefore, we decided that 
the Plan does not have to pre-approve myocardial perfusion imaging.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued skilled nursing facility (SNF) stay. 
 
You asked the Plan to pre-approve a continued SNF stay. You say that you are not ready to come home and 
need to get stronger. The Plan denied your request. The Plan says you have no daily skilled nurse or therapist 
needs. 
 
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 a continued SNF stay. Our reviewer 
says that based on the medical records provided there is no documentation that you require skilled nursing 
services. Our physician reviewer found the records do not document the need for intravenous medications, new 
tube feeding or ostomy care or daily complex wound care or respiratory care. You do not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You 
do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. Our reviewer also found you do not require daily skilled nursing and/or skilled therapy 
on an inpatient basis in a skilled nursing facility (SNF) setting.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a continued SNF stay have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continued skilled nursing facility (SNF) stay.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee had an above knee amputation and is not 
safe to be home. You say that they need an oversight due to complicated medical history and their level of care 
cannot be met elsewhere. The Plan denied your request. The Plan says that the requested admission to an IRF is 
not medically necessary. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollee has had a significant decline in function and does require the intensive therapies provided in 
the acute inpatient rehabilitation setting. She requires total assistance with toileting, maximum assistance with 
lower body dressing and bathing and minimum assistance with upper body dressing. She also requires 
moderate assistance with bed mobility and transfers. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 1, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
 
 
 
 
 
 We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on February 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pneumatic compression devices (E0675, E0673) provided on 
December 14, 2021. 
 
You asked the Plan to pay for pneumatic compression devices. You say that the items at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for pneumatic 
compression devices have not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. The rules also say that a PCD coded 
as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
 
  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCDs have not been met. Specifically, these items are not a covered benefit of Medicare or the 
Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for pneumatic compression devices (E0675, E0673) provided on December 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses lens-tinting (V2744) and anti-reflective coating 
(V2750) provided on March 24, 2022. 
 You asked the Plan to pay for lens-tinting and anti-reflective coating. You say that the features at issue were a 
medical necessity for you. The Plan denied your request. The Plan says rules for payment have not been met. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one pair of standard eyeglasses or contact lenses after each cataract surgery that 
includes insertion of an intraocular lens. 
 
We looked at the file and the Plan's rules. In this case, the features at issue are not features of standard 
eyeglasses. Based on this information, we decided that the Plan's rules for coverage of lens-tinting and anti-
reflective coating have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses 
lens-tinting (V2744) and anti-reflective coating (V2750) provided on March 24, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for nail debridement services (procedure code 11720-59) provided to the 
enrollee on February 23, 2022. 
 
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 that the documentation does not clearly indicate that the debridement of nails and paring/cutting 
of lesions were performed at separate sites. 
 
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 11720 is "Debridement of nail(s) by any method(s); 1 to 5." 
 
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 the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that after a review of the current CCI 
edits, when procedure code 11055 is billed and billed performed with procedure code 11720, there is a 
relationship between the codes. CPT 11720 is a column II code for the column I code 11055, but you may use a 
NCCI-associated modifier to override this edit. Modifier 59 would be appropriate in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
nail debridement services (procedure code 11720-59) provided to the enrollee on February 23, 2022.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5050) provided on January 18, 2022. 
 
You asked the Plan to pay for hearing aids. You say that the non-preferred brand of hearing aids were 
prescribed as a necessity for your care. The Plan denied your request. The Plan says rules for payment have not 
been met because you did not obtain the required brand of hearing aids. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays only 
for required-brand hearing aids. 
 
We looked at the file and the Plan's rules. In this case, you have purchased hearing aids that are not the Plan's 
required brand. Based on this information, we decided that the Plan's rules for coverage of hearing aids have 
not been met. Therefore, we decided that the Plan does not have to pay for hearing aids (V5050) provided on 
January 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing 81439, 
81286, 81238, 81410, 81411 and 81479 provided April 16, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that please find the attached appeal and process the 
claim towards payment. The Plan denied your request. The Plan says Medicare non-covered service. Unlisted 
procedure code. 
 
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 find that CPT codes 81439, 81286, 81238, 81410, 81411 and 81479 is not supported in the medical record. Specifically genetic cardiovascular screening testing does not meet the definition of 
cardiovascular disease screening. Based on this information, we decided that Medicare rules for coverage of the 
genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for cardiac risk 
assessment genetic screening testing 81439, 81286, 81238, 81410, 81411 and 81479 provided April 16, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says step therapy criteria have not been 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 Injectafer. Our reviewer says that this 
drug is not medically reasonable and necessary for the enrollee's condition. Our physician reviewer found the 
Plan requires a trial of Infed and Venofer before they will approve the requested drug. In his case, the patient 
has not tried and failed the required drug(s). There is no documentation provided indicating that the plans 
required drug(s) 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services provided on February 10, 2022. 
 
You asked the Plan to pay for the pathology services. You say that this claim should be paid because this 
patient has active coverage with the Plan. The Plan denied your request. The Plan says the claim must first be 
processed by the patient's primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. 
 First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the 
provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for 
reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has identified the 
primary insurer and contacted you to advise you to submit the claim there. As the secondary insurer, the Plan 
cannot be held responsible for the pathology services until the primary insurer has denied the claim for these 
services. Therefore, we decided that the Plan does not have to pay for pathology services provided on February 
10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 25, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on January 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Via disc injection. 
 
You asked the Plan to pre-approve a Via disc injection. 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. 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 a Via disc injection. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered experimental/investigational at this time. 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 a Via disc injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Via disc injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fulphila. 
 
You asked the Plan to pre-approve Fulphila. 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 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 Fulphila. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided and 
the Medicare-approved major drug compendia there is no documentation that the Fulphila at issue in this case 
meets Medicare criteria for safe and effective. Fulphila is indicated for chemotherapy-induced neutropenia 
prophylaxis, to decrease the incidence of febrile neutropenia, in patients with nonmyeloid malignancies 
receiving myelosuppressive chemotherapy associated with a clinically significant incidence of febrile 
neutropenia. Chronic, cyclic neutropenia is not a medically-accepted indication for use of Fulphila. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Fulphila have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Fulphila.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require the intensity of services provided at an IRF. Your needs can be 
met at a lower level of 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the reinsertion of spinal fixation device (22849) provided on 
September 10, 2021. 
 
You asked the Plan to pay for the reinsertion of spinal fixation device (22849). You say that the codes billed 
are not bundled and do not require a modifier. You say that the claim should be reviewed and paid at the 
allowed amount. The Plan denied your request. The Plan says this procedure is considered inclusive to CPT 
code 22855. 
 
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 22849 is reinsertion of spinal fixation device. 
 
  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 the reinsertion of spinal fixation device (22849). Our 
reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our 
reviewer found that the operative report describes an exploration and removal of prior plating C4-C5 and 
revision of anterior fusion C4-C5. In this case, CPT code 22849 would be inclusive to the revision. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the reinsertion of spinal fixation device (22849) have not been met. Therefore, 
we decided that the Plan does not have to pay for the reinsertion of spinal fixation device (22849) provided on 
September 10, 2021.