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

 
We decided that the Plan does not have to pay for the observation care discharge day management services 
(99217) provided on February 10, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hospital observation services. You say that your physicians are hospital based 
and your providers rely on the facility to obtain the proper authorization. The Plan denied your request. The 
Plan says services from nurse practitioners are not covered under open access unless preauthorized. 
 
 
 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 observation care discharge day management 
services (99217) provided on February 10, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a Keytruda injection received on January 
28, 2022. 
 
You asked the Plan to waive the copayment for an injection received on January 28, 2022. You say that you 
understood that Keytruda is covered under your plan and ask why you are paying this coinsurance. The Plan 
denied your request. The Plan says, when you get these services in-network, you pay a 0% copayment for 
Medicare covered Part B allergy antigens. The plan also says, when you get these services in-network, you pay 
a 20% coinsurance for all other Medicare-covered Part B drugs. 
 
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 20% 
coinsurance for Medicare Part B Prescription Drugs.  You have been asked to pay $2110 for an injection on January 28, 2022. An injection falls within the Medicare 
Part B Prescription Drugs benefit category. The provider billed $34,200; the allowed amount was $10,550 
($10,550 x 20% = $2110).  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 Keytruda injection 
received on January 28, 2022.  
 
Please note, you requested information regarding your maximum out-of-pocket expense. Per your contract with 
the Plan, your maximum in-network, out-of-pocket amount is $3,900. If you have additional questions about 
your maximum out-of-pocket amount, please contact the Plan.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex interspinous spacer for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says experimental and investigational procedures 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.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that it has not been sufficiently established that the Vertiflex interspinous spacer device is medically 
reasonable and necessary for the enrollee in this case. Low quality evidence from medical studies indicates that 
outcomes regarding pain, functional status, and quality of life are similar with interspinous process devices 
when compared to surgery. Treatment failure was significantly higher in patients treated with interspinous 
process devices compared to decompressive surgery because of complications. Interspinous process devices do 
not appear to be helpful in patient with spondylolisthesis, as this enrollee has. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex interspinous spacer for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you need this for everyday living because the 
lower part of your body is numb already. 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 pre-approve a shower chair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is necessary. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate care in the current inpatient acute 
care setting and is unstable for transfer to an LTACH. The Plan also says medically necessary acute and critical 
care at the current facility will continue to be covered. Once the enrollee is stable enough for transfer and/or if 
the enrollees clinical circumstances change, an alternate level of care may be considered.   
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee seems to be more stable now but still requires additional short-term acute 
care hospital services. These services can be completed at the current facility until the enrollees condition is 
more stable, at which point, a lower level of care may be appropriate. There are no services provided at the 
LTACH that the enrollee requires and are not already available and covered at the current facility. Our reviewer 
also found transfer to an LTACH is not medically necessary because the enrollee is not yet fully stable.  Our reviewer says transfer would not be clinically advantageous at this time and completion of treatment at the 
current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oxygen concentrator and sales tax. 
 
You asked the Plan to pay for an oxygen concentrator and sales tax. You say that this was medically necessary. 
The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for an oxygen concentrator and sales tax.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient appears to be somewhat unstable for transfer due to worsening CXR 
findings. The patient requires short-term additional acute care hospital services that can be completed at the 
current facility until more stable and appropriate for a lower level of care. The patient does not require services 
at the LTACH that are not already available at the current facility. Transfer to LTACH is not medically 
necessary as the patient is currently clinically unstable and as it would not be clinically advantageous at this 
time. Completion of treatment at the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency department visit (99285) radiologic examination 
(73590) radiologic examination, hip, unilateral, with pelvis when performed (73501) provided November 16, 
2021. 
 
You asked the Plan to pay for the emergency visit. You say that you are the free-standing emergency room and 
is already enrolled with Medicare. You are eligible to perform the services because you are the Medicare 
certified provider. The Plan denied your request. The Plan says that Medicare does not cover services that are 
not performed by a Medicare certified provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. the Plan has not substantiated their reason to continue to deny the claim. The 
provider has submitted their letter showing they have temporary Medicare billing privileges which is dated 
prior to this date of services. Therefore, we decided that the Plan has to pay for the emergency department visit 
(99285) radiologic examination (73590) radiologic examination, hip, unilateral, with pelvis when performed 
(73501) provided November 16, 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 pay for a rest home visit (99336) provided on October 28, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the rest home visit. You say that the services should be covered as they were 
medically necessary. The Plan denied your request. The Plan says the services denied correctly as prior 
authorization was not obtained. 
 
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 a rest home visit (99336) provided on October 28, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an auricular percutaneous neurostimulator 
(64555, L8679). 
 
You asked the Plan to pre-approve an auricular percutaneous neurostimulator. You say that the requested item 
is a medical necessity for you. The Plan denied your request. The Plan says rules for coverage for the requested 
item have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that payment may be made for implanted peripheral 
nerve stimulators in which electrodes are surgically placed under the skin around a nerve. The rules also say 
that acupuncture is only covered when provided for low back pain when furnished by a licensed acupuncturist.   
 
We looked at the file and Medicare rules. We find that this device does not meet the Medicare definition for an 
implanted nerve stimulator because the device involves needles inserted around the nerves and not electrodes 
being surgically implanted. The Food and Drug Administration (FDA) clearances for devices of this type are as 
electro-acupuncture devices. Since acupuncture is not covered by Medicare for any condition when rendered 
through a device rather than by a licensed practitioner, we find that Medicare coverage criteria for this auricular 
stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve placement of 
an auricular percutaneous neurostimulator (64555, L8679).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The 
Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the patient is a 71-year-old male with unresectable tongue cancer status post 
palliative radiation therapy who was admitted to the acute care hospital with oral cavity bleed complicated by 
pneumonia. He required tracheostomy, was treated for the bleeding which stopped, was treated with antibiotics, 
scopolamine patch, Keytruda. Recent notes describe the patient as having aspirated but now tolerating tube 
feeds again, but continues to require frequent suctioning from trach and leukocytosis with unclear pulmonary 
status. The patient appears to still be somewhat unstable and requires additional acute care hospital services 
that can be completed at the current facility until more clinically stable. The patient does not require services at 
the LTACH that are not already available at the current facility.  Transfer to LTACH is not medically necessary as the patient is unstable. Completion of treatment at the current 
facility is recommended until clinically stable. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tele-health visit (99443) provided on January 12, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the tele-health visit. You say that the services should be paid. The Plan denied 
your request. The Plan says the service denied correctly as you are out-of-network and there was no prior 
authorization obtained. 
 
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 a tele-health visit (99443) provided on January 12, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional supplies and materials provided to the enrollee on 
November 12, 2021. 
 
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 this code is not allowed to be billed in conjunction with another 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. 
 
 
 
 
 
 We find that CPT code 99072 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99072 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the services have not been met. Therefore, we decided that the Plan does not have to pay for additional 
supplies and materials provided to the enrollee on November 12, 2021.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for duplex scan of extracranial arteries (code 93880) provided on 
September 2, 2021. 
 
You asked the Plan to pay for the duplex scan of extracranial arteries. The Plan denied your request. The Plan 
says that the duplex scan of extracranial arteries is experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 pay for the duplex scan of extracranial arteries. Our 
reviewer says that the requested duplex scan of extracranial arteries is considered medically reasonable and 
necessary in this case. Our physician reviewer found that the enrollee is a 75-year-old woman with a history of 
carotid stenosis seen on computed tomography (CT) scan. A history of carotid stenosis is an accepted and 
medically necessary indication for carotid artery duplex coverage. The carotid duplex and CT scan provide 
complementary (not simply redundant) information, and the carotid duplex would allow for future comparison 
without the need for contrast dye and radiation.  
 
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 duplex scan of extracranial arteries have been met. Therefore, we decided 
that the Plan has to pay for duplex scan of extracranial arteries (code 93880) provided on September 2, 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically reasonable 
and necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the patient is a 63-year-old male who was admitted to the acute care hospital 
with acute on chronic respiratory failure due to stage IV chronic obstructive pulmonary disease, head and neck 
cancer requiring a feeding tube complicated by pneumonia requiring antibiotics. The patient appears to be more 
stable and improving and should only require short-term additional acute care hospital services that can be 
completed at the current facility until more appropriate for a lower level of care. The patient does not require 
services at the LTACH that are not already available at the current facility. Transfer to LTACH is not 
medically necessary as it would not be clinically advantageous at this time. Completion of treatment at the 
current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.