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

 
We decided that the Plan does not have to pay for nurse practitioner services provided on February 2, 2022 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nurse practitioner services. You say that the facility was responsible for 
getting authorization and these services were medically necessary. The Plan denied your request. The Plan says 
unauthorized, non-plan care is not covered. 
 
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 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 nurse practitioner services provided on February 2, 2022 by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous lumbar intravertebral disc injection. 
 
You asked the Plan to pre-approve percutaneous lumbar intravertebral disc injection. You say that a 
percutaneous lumbar intravertebral disc injection is medically necessary. The Plan denied your request. The 
Plan says percutaneous lumbar intravertebral disc injection is not medically necessary. 
 
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 percutaneous lumbar intravertebral disc 
injection. Our reviewer says that percutaneous lumbar intravertebral disc injection is not considered medically 
reasonable and necessary. Our physician reviewer found this is considered 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 percutaneous lumbar intravertebral disc injection have not been met. Therefore, 
we decided that the Plan does not have to pre-approve percutaneous lumbar intravertebral disc injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020) purchased on January 29, 2022, from an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the frames. You say that you would like this claim to be reconsidered for 
coverage because the purchase of these correct frames saved the cost of new identical prescription lenses. The 
Plan denied your request. The Plan says you used an OON provider and have already used your routine vision 
benefits for the 2022 and 2023 plan years. 
 
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 these services when they are purchased at a plan provider location. 
 
We looked at the file and the Plan's rules. The record shows that you purchased these frames from an OON 
provider, and exhausted your eyewear allowance on January 11, 2022. Based on this information, we decided 
that the Plan's rules for coverage of the frames have not been met. Therefore, we decided that the Plan does not 
have to pay for the frames (V2020) purchased on January 29, 2022, from an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant at surgery services provided for code 37140 on 
January 11, 2022. 
 
You asked the Plan to pay for the assistant at surgery services. You say that you believe that an assistant at 
surgery can be billed with this procedure. The Plan denied your request. The Plan says assistant at surgery 
services are not covered for this procedure. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 37140. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
assistant at surgery services have not been met. Therefore, we decided that the Plan does not have to pay for 
assistant at surgery services provided for code 37140 on January 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to change the coinsurance and they have properly assessed the 
maximum out-of-pocket amount for the chemotherapy drug and medical services provided from December 1, 
2021, to December 31, 2021. 
  You asked the Plan to change the coinsurance and properly assess the maximum out-of-pocket amount for the 
chemotherapy drug and medical services. You say that you hit your yearly maximum out-of-pocket prior to the 
dates of service so there should not be a coinsurance charge. The Plan denied your request. The Plan says the 
proper coinsurance was charged because the enrollee did not hit their maximum out-of-pocket prior to the dates 
of service. 
 
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 $7,550 
maximum out-of-pocket amount. The amounts you pay for copayments and coinsurance for in-network 
covered services count toward this maximum out-of-pocket amount. Your contract with the Plan also clearly 
says that you must pay a 20% coinsurance Medicare-covered part b chemotherapy drugs and other part b drugs.  
 
The yearly explanation of benefits sheet shows that the enrollee did not hit the yearly maximum out-of-pocket 
amount of $7,550 until December 27, 2021. On December 2, 2021, the total amount allowed for the injection 
was $3,760.27 with a coinsurance charge of $398.17 which is less than the proper coinsurance amount of 
$752.05 ($3,760.27 total amount allowed x 20% coinsurance). The total amount allowed for the infusion was 
$9.13 with a coinsurance amount of $1.83 ($9.13 total amount allowed x 20% coinsurance). The total amount 
for both coinsurances was $400 ($398.17 coinsurance + $1.83 coinsurance). 
 
You have been asked to pay a $400 coinsurance for the chemotherapy drug and medical services. The 
maximum out-of-pocket amount falls within the What is The Most You Will Pay for Medicare Part A and Part 
B Covered Medical Services benefit category. The chemotherapy drug falls within the Medicare Part B 
Prescription Drugs 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 change the coinsurance and they have 
properly assessed the maximum out-of-pocket amount for the chemotherapy drug and medical services 
provided from December 1, 2021, to December 31, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S5130 billed for date of service March 27, 
2022, to March 31, 2022. 
 
You asked the Plan to pay for procedure code S5130. You say that authorization was obtained for the services 
in this case. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S5130 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S5130 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S5130 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S5130 billed for date of service March 27, 2022, to March 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from January 24, 
2020, to January 30, 2020. 
 
You asked the Plan to pay for the inpatient hospital services. You say that you believe this claim should be 
reprocessed for payment. The Plan denied your request. The Plan says the original claim has a processed date 
of April 20, 2020, and this corrected claim was received on February 8, 2022. The Plan also says that this is 
past the allowed 12-month timeframe. 
 
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 hospital services was not filed until February 8, 2022. 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 hospital services provided from 
January 24, 2020, to January 30, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the gene analysis provided on June 14, 2021. 
 
You asked the Plan to pay for the testing services. You say that the physician ordered specialized testing for 
this enrollee. The Plan denied your request. The Plan says that if one procedure evaluates multiple genes, the 
lab shall report only one unit of service with one 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, the CPT Code Manual definition of code 81275 is KRAS (Kirsten rat sarcoma viral oncogene 
homolog) (e.g., carcinoma) gene analysis; variants in exon 2 (e.g., codons 12 and 13). We find that CPT code 
81275 is supported in the medical record. Specifically, the records show that the KRAS gene analysis covering 
codons 12, 13, and 61 were provided. The testing at issue detects specific mutations in the KRAS gene. The 
testing did not evaluate multiple genes using a next generation sequencing procedure. Based on this 
information, we decided that Medicare rules for coverage of the testing services have been met. Therefore, we 
decided that the Plan has to pay for the gene analysis provided on June 14, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you could be safely treated in a lower level. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for a stroke. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found 
that your condition does not meet Medicare criteria for IRF 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 16 additional aquatic therapy visits (97113). 
 
You asked the Plan to pre-approve the additional aquatic therapy visits. You say that the enrollee has only been 
seen and approved for four visits. You also say that the enrollee needs more time to progress, and needs 
moderate assistance with a therapist in the pool with them for therapy. The Plan denied your request. The Plan 
says the notes provided do not document one of the conditions for which Medicare considers aquatic therapy 
reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 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 additional aquatic therapy visits. 
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found the clinical documentation shows that 
the enrollee does have complex functional impairments and chronic pain syndrome, and would benefit from 
skilled therapy. Our reviewer also found that there is nothing in clinical documentation that shows why the 
listed functional goals require aquatic therapy. 
 
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 additional aquatic therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 16 additional aquatic therapy visits (97113).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided April 15, 2021, to May 4, 
2021. 
 
You asked the Plan to pay for the inpatient services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if the provider has preadmission services 
performed more than three days prior, the claim will deny and the provider would need to submit a corrected 
claim in order to receive payment. 
 
We looked at the file and Medicare rules. Review of the file shows that the claim received by the provider 
shows dates of service from April 15, 2021, through May 04, 2021, with an admission date of April 22, 2021. 
The first billed date of service April 15, 2021 is beyond the 3 day payment window allowed. This means that 
this claim is not payable as billed. Based on this information, we decided that Medicare rules for coverage of the inpatient services have not been 
met. Therefore, we decided that the Plan does not have to pay for the inpatient services provided April 15, 
2021, to May 4, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that skilled services can be provided at the home with home health care 
services. 
 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 services. Our reviewer says that 
SNF services are not medically reasonable and necessary. The enrollee had an uncomplicated hip replacement 
and had good function post-op without daily skilled nursing needs. Her level of function is consistent with 
home care rehabilitation as she can improve with repetitive exercise and support from a non-skilled person. 
Daily skilled therapy is not necessary to restore function. Our physician reviewer found that the enrollee's 
condition does not meet Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that facet joint injections are medically 
necessary. The Plan denied your request. The Plan says facet joint injections do not meet the Medicare LCD 
coverage criteria. 
 
The Plan follows Medicare 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 pre-approve facet joint injections. Our reviewer says 
that facet joint injections are not medically necessary. Our physician reviewer found that there were no 
diagnostic MBBs conducted first. Further, the enrollee has not finished physical therapy. Therefore, at this 
point 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the ventilator is to be used for the treatment 
of COPD and OSAS. The Plan denied your request. The Plan says the request for a home mechanical ventilator 
set in AVAPS mode with auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the record indicates that you have 
obstructive sleep apnea. The rules do not indicate that this is a condition for which coverage is available.  
Notwithstanding this fact, the provided primary source documentation does not contain sufficient detailed 
information in the medical record to justify the treatment selected. You could be treated with a BiPAP machine 
with AVAPS capability. The plan has indicated coverage for such a device is available upon request. The 
elements of the coverage criteria are not satisfied. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nebulizer with compressor (E0570) provided on January 
18, 2022. 
 
You asked the Plan to pay for a nebulizer with compressor. You say that the item at issue was billed correctly. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that the item at issue in this case is a rental-only item and requires an RR modifier. The RR modifier 
was not billed on the claim. Based on this information, we decided that Medicare rules for coverage of a nebulizer with compressor have not been met. Therefore, we decided that the Plan does not have to pay for a 
nebulizer with compressor (E0570) provided on January 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that the enrollee is not at the level needed and the 
ventilator will help get the needed amount of oxygen. The Plan denied your request. The Plan says the denial of 
authorization for this device is correct, because ventilators used to provide positive airway pressure therapy - 
regardless of the underlying medical condition - are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilators are not covered when used to provide 
positive airway pressure therapy.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
portable ventilator.