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

We decided that the Plan does not have to pre-approve Aduhelm.
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 services are not medically necessary.
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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of late
onset Alzheimer's disease without behavioral disturbance. Aduhelm is not FDA-approved for the treatment of
Alzheimer's disease in patients with mild cognitive impairment or mild dementia stage of disease. The
documentation does not support a diagnosis of Alzheimer's disease with mild cognitive impairment in this
enrollee. Aduhelm is therefore not safe and effective or reasonable and 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 Aduhelm.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Kerecis Omega3, skin graft (CPT code Q4158), for the enrollee.
You asked the Plan to pre-approve the skin graft. You say that the enrollee would benefit from using the product and they could develop an infection or losing both feet if this procedure is not done. The Plan denied your request. The Plan says your request is not medically necessary because these items are not separately payable.
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 skin graft. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that there is no documentation provided indicating that the wound has not responded to standard wound therapy. The requested Kerecis Omega3, skin graft (CPT code Q4158) is not medically necessary or reasonable. 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 skin graft have not been met. Therefore, we decided that the Plan does not have to pre-approve the Kerecis Omega3, skin graft (CPT code Q4158), for the enrollee
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s) coded 99072 provided from December 21, 2020 to January 21, 2021.
You asked the Plan to pay for the additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s). You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.
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 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease. We find that CPT code 99072 is not supported in the medical record. Specifically, code 99072 has a status code of "B". This means that these services are considered bundled with the services provided to the enrollee on the same dates of service and are not eligible for separate payment. Based on this information, we decided that Medicare rules for coverage of the additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s) have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s) coded 99072 provided from December 21, 2020 to January 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to make additional payment for the inguinal hernia repair services provided on March 9, 2021.
You asked the Plan to make additional payment for the hernia repair services. You say that you feel that this claim is grossly underpaid because the Plan had previously agreed to pay these services at the network level rate. You were under the impression that the plan would pay the entire billed charge of $10,550 for this surgical service. You state that you ensured that the claim would be paid at 100% of the billed charges. The Plan denied your request. The Plan says this was correctly paid at the full Medicare allowable rate for this service. No additional payment can be made.
The Plan must follow Medicare rules. Medicare rules say that non-contract providers must accept as payment in full payment amounts applicable in Original Medicare. We looked at the file and Medicare rules. We find that this provider is a Medicare-participating physician. There is no evidence in the file that the Plan agreed to pay 100% of the billed charges for these Medicare-covered services. Providers must accept the Medicare allowed payment rate as payment in full for services rendered to Medicare beneficiaries.
We found no applicable exception which would require payment in excess of the Medicare allowable to be paid by the Plan or the Medicare beneficiary. Therefore, we decided that the Plan does not have to make additional payment for the inguinal hernia repair services provided on March 9, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on April 9, 2021.
You asked the Plan to pay for physical therapy. The Plan denied your request. The Plan says services rendered
by a non-par provider require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
physical therapy. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for physical therapy provided on April 9, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pre-approve the emergency care services (CPT code(s): 80053, 83880, 84484, 36415, 85025, 71045 and 93005) provided to the enrollee on April 24, 2021, by an out-of-network provider.
You asked the Plan to pre-approve the emergency care services. You say that the services were medically necessary. The Plan denied your request. The Plan says that this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the emergency care services have been met. Review of the records show that the enrollee received emergency care services on April 24, 2021. The rules say that a Medicare Health Plan is financially responsible for emergency services regardless of whether the services are obtained within or outside the Health Plan. Emergency services are covered whether there is prior authorization for the services. An emergency is defined as when a person would believe that without immediate medical attention there would be serious jeopardy to his or her health Therefore, we decided that the Plan has to pre-approve the emergency care services (CPT code(s): 80053, 83880, 84484, 36415, 85025, 71045 and 93005) provided to the enrollee on April 24, 2021, by an out-of-network provider.
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 supervision of a nursing facility patient (CPT code 99380) provided to the enrollee on March 24, 2021.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says CPT code 99380 has a status indicator of 'B' on the Centers for Medicare & Medicaid
Services (CMS) Physician Relative Value File and is always bundled into payment for other services not specified and no separate payment is made per Medicare.
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 the services has a bundled relationship with code 99380 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 supervision of a nursing facility patient (CPT code 99380) provided to the enrollee on March 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cytopathology (CPT code 88112) provided to the enrollee on April 30, 2021, by an out-of-network provider.
You asked the Plan to pay for the cytopathology. You say that the doctor's office failed to send in a preauthorization form for approval. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.
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 the cytopathology (CPT code 88112) provided to the enrollee on April 30, 2021, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (CPT code G0482) provided to the enrollee on February 24, 2021.
You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. CPT code G0482 (1 Unit) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on February 24, 2021, and received by the lab on February 26, 2021. Of note, the patient resides in Alabama (AL) and the billing laboratory is located in Georgia (GA); therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided that the Plan does not have to pay for the drug testing (CPT code G0482) provided to the enrollee on February 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87486-59, 87496-59, 87498-59, 87532-59, 87541-59, 87581-59, 87634-59, 87640-59, 87798-91 provided to the enrollee on August 24, 2020.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87486-59, 87496-59, 87498-59, 87532-59, 87541-59, 87581-59, 87634-59, 87640-59, 87798-91 provided to the enrollee on August 24, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF 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 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 daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the anesthesia for upper gastrointestinal endoscopic procedures provided on February 9, 2021.
You asked the Plan to waive the deductible for these services. You say that you should not have to pay this amount. The Plan denied your request. The Plan says that there is a $400 in-network deductible that must be met before the Plan starts to pay their share for medical services.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $400 deductible which applies to covered medical services. The item or service you asked the Plan to waive the deductible for falls within the covered in-network medical services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $400 deductible which applies to in-network covered medical services. This cost sharing is a contractual obligation that had not been met at the time these services was received on February 9, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the anesthesia for upper gastrointestinal endoscopic procedures provided on February 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames (V2020), spherocylinder trifocal lenses 
(V2311) and anti-reflective coating (V2750) provided on April 15, 2021. 
 
You asked the Plan to pay for eyeglass frames, trifocal lenses and anti-reflective coating. You say that you 
disagree with the codes and you are not sure why the optical frame is being denied. The Plan denied your 
request. The Plan says you exhausted your benefit, and you are responsible for the remaining balance. 
 
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 contract says that you receive a $250 allowance to use towards the purchase of eyewear. If 
the eyewear you purchase is more than $250, you pay for the difference. 
 
We looked at the file and the Plan's rules. The records show you exhausted your $250 maximum allowed 
benefit on April 15, 2021. The records also show that you purchased eyeglass frames at $115, trifocal lenses at 
$220 and anti-reflective coating at $89, for a total amount of $424 ($115 + $220 + $89 = $424). You received 
the Plan's $250 allowance benefit, leaving a balance of $174 ($424 - $250 = $174). The records also show that 
your $250 allowance benefit covered your frames at $115 and $135 applied to the trifocal lenses. You are 
responsible for the remaining balance of the trifocal lenses and the anti-reflective coating which totals $174. 
Based on this information, we decided that the Plan's rules for coverage of eyeglass frames, trifocal lenses and 
anti-reflective coating have not been met. Therefore, we decided that the Plan does not have to pay for eyeglass 
frames (V2020), spherocylinder trifocal lenses (V2311) and anti-reflective coating (V2750) provided on April 
15, 2021.  
 
Your complaint about the coding is not a valid appeal for medical coverage. This part of your complaint is a 
grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types 
of complaints.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from February 24, 2021, 
through February 26, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was medically 
necessary. The Plan denied your request. The Plan says that your medical records sent in for review show that 
your condition meets the medical necessity criteria for an observation level of care. 
 
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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the medical record showed that at the time of the inpatient admission, the admitting 
physician reasonably expected that your necessary hospital care (including earlier emergency department 
and/or observation care) would span two 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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from February 24, 2021, through February 26, 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 pre-approve a referral for continuity of care with an out-of-network 
dermatologist. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says this care can be provided by any in-network provider. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 referral. Our reviewer says that the 
requested referral is not medically reasonable or necessary. Our physician reviewer found that any board-
certified dermatologist will be able to take care of the enrollee's needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the referral have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a referral for continuity of care with an out-of-network dermatologist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transfer bench. 
 
You asked the Plan to pre-approve the bench. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a transfer bench.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0429) provided October 27, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim was not correctly billed. 
 
The Plan must follow Medicare rules. Medicare rules say that in cases where the patient is pronounced dead 
after the ambulance is called, providers must report the A0428 (BLS) HCPCS code. 
 
We looked at the file and Medicare rules. The provider billed code A0429. Based on the records, code A0428 
must be billed. Based on this information, we decided that Medicare rules for coverage of the ambulance 
services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services 
(A0429) provided October 27, 2020.