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

 
We decided that the Plan does not have to pre-approve Viberzi. 
 
You asked the Plan to pre-approve Viberzi. You say that Viberzi is medically necessary. The Plan denied your 
request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Viberzi.  
 
Benefits for Viberzi may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Spravato 56mg solution. 
 
You asked the Plan to pre-approve Spravato. You say that Spravato is medically necessary. The Plan denied 
your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Spravato 56mg solution.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
February 27, 2021, to March 3, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the determination to remove principal diagnosis code A41.51 (Sepsis due to Escherichia 
coli [E. coli]) and secondary diagnosis code G93.41 (Metabolic Encephalopathy) and sequence ICD-10 code 
N39.0 is appropriate. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871 (SEPTICEMIA OR SEVERE SEPSIS 
WITHOUT MV >96 HOURS WITH MCC). 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 
services. Our reviewer says that the services at issue in this case were not supported by the medical records. 
Our physician reviewer found a review of the medical records shows that the enrollee presented to the facility 
with a main complaint of generalized weakness. While the provider documents the condition of sepsis in the 
record, it is maintained that the medical records support was incomplete regarding a diagnosis of sepsis. The 
review has determined that the decision to remove A41.51 was appropriate. The appropriate DRG is DRG 690: 
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from February 27, 2021, to March 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received on September 7, 2021. 
 
You asked the Plan to pay for the drugs. You say that this denial should be fixed at the earliest convenience. 
The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs received 
on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist office visits provided from 
August 12, 2021, to August 26, 2021. 
 
You asked the Plan to waive the copayments for the specialist office visits. You say that the appointment s did 
not help your problems at all. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for each in-person specialist visit.  
 
You have been asked to pay a $35 copayment for each of the specialist office visits, for a total of $70. The 
specialist office visits fall within the Physician/Practitioner Services, Including Doctor's Office Visits benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayments for specialist office visits provided from August 
12, 2021, to August 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for needle electromyography (procedure code 95870) provided 
to the enrollee on September 2, 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 the diagnosis is not covered for this request. 
 
The Plan must follow Medicare rules. Medicare rules say that EMG may be covered for certain specific 
indications. 
 
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 services. Our reviewer says that that in 
this case, the EMG that was performed was not for an indication for which the guidelines readily support 
provision of this service. Our physician reviewer found the current literature remains divided on the overall net 
utility of EMG in thyroid surgery. Given this combination of factors, it cannot be said that this request was 
reasonable and 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for needle electromyography (procedure code 95870) provided to the enrollee on September 2, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received on November 6, 2021, and 
November 7, 2021. 
 
You asked the Plan to pay for the drugs. 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 Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs received 
on November 6, 2021, and November 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received on August 15, 2021. 
 
You asked the Plan to pay for the drugs. 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 Medicare Part B generally does not pay for self-
administered drugs.  
 The self-administered drugs requested here are not among the types which are covered by Medicare Part B. 
Therefore, we decided that the Plan does not have to pay for self-administered drugs received on August 15, 
2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services (90834) provided on June 25, 
2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration because 
the services rendered were medically necessary. The Plan denied your request. The Plan says there is no 
referring physician listed on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that when services are rendered by a Clinical 
Psychologist, if the patient consents, you must attempt to consult their attending or primary care physician 
about the provided services and document the consent or declination date to consultations and date of the 
consultations in the patients medical record. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have not been met. Specifically, the claim submitted does not have a referring physician listed. Additionally, the medical records do not support that this provider consulted with the 
member's primary care physician or attending physician regarding the services provided. Therefore, we decided 
that the Plan does not have to pay for the psychotherapy services (90834) provided on June 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (74185) provided on October 16, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 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 74185 
is a column II code to column I code 74183. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the services (74185) provided on October 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 29, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you did not know prior authorization was required. 
The Plan denied your request. The Plan says the rendering provider is an out-of-network provider and there 
was no approved authorization. Also, the services rendered was not urgent or emergent. 
  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 an office visit provided on September 29, 2021, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 4, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you did not know prior authorization was required. 
The Plan denied your request. The Plan says the rendering provider is an out-of-network provider and there 
was no approved authorization. Also, the services rendered was not urgent or emergent. 
  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 an office visit provided on October 4, 2021, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery and advanced 
imaging services provided on August 25, 2021, and September 1, 2021. 
 
You asked the Plan to waive the copayment for the outpatient surgery and advanced imaging services. You say 
that the services should be covered, and you feel you should not owe anything. The Plan denied your request. 
The Plan says the cost-sharing applied correctly based on the services provided. 
 
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 $350 
copayment and a $275 copayment for Outpatient hospital services.  
 
 You have been asked to pay a $350 copayment for an outpatient surgery and a $188.68 copayment for 
advanced imaging services, which is less than the $275 stated in the Plans contract. Outpatient surgeries and 
advanced imaging services fall within the Outpatient hospital services 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 an outpatient surgery and advanced imaging services provided on 
August 25, 2021, and September 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent limb compression device accessory (E0673) 
provided on June 24, 2021. 
 
You asked the Plan to pay for the intermittent limb compression device accessory. You say that you would like 
reconsideration because the billed supply was medically necessary for the treatment of the member's condition. 
The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for 
use in the facility. The Plan follows Medicare rules. The rules state that pneumatic compression device (PCD) related accessories 
are eligible for reimbursement only when the appropriate, related base PCDs (E0650, E0651, E0652, E0675) 
meets the applicable coverage criteria for that type of PCD. 
 
We looked at your request, the file and Medicare rules. Based on this information we have decided that 
Medicare criteria for coverage of the requested accessory have not been met. Specifically, the documentation 
does not indicate that a PCD has been ordered or if a PCD would meet Medicare criteria for coverage. As such, 
the PCD related accessory cannot be covered. Therefore, we decided that the Plan does not have to pay for 
intermittent limb compression device accessory (E0673) provided on June 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical knee arthroscopy (procedure code 29873) provided 
to the enrollee on September 29, 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 the records do not support the services billed. 
 
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 29873 is Arthroscopy, knee, surgical; with lateral 
release. 
 
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 not supported by the medical records. Our reviewer found the records do not support that 
arthroscopy, knee, surgical; with lateral release was rendered in this case. The surgical procedure that was 
performed on 9/29/21 was an arthroplasty. The provided operative note does not indicate any arthroscopic 
procedure having been performed.  Therefore, the records do not support CPT 29873 and that arthroscopy, knee, surgical with lateral release was 
rendered in this case. There is no evidence that there was any arthroscopic procedure performed on 9/29/21. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for surgical knee arthroscopy (procedure code 29873) provided to the enrollee on September 29, 
2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the physical and occupational therapy 
services (97165, 97161) provided on September 22, 2021. 
 
You asked the Plan to waive the copayment for physical an occupational therapy. You say that you feel that the 
therapist did nothing and did not even spend five minutes with you. The Plan denied your request. The Plan 
says this claim was processed correctly, and your share of the cost was assessed in accordance with your 
contract. Medical records were provided which support that you received physical and occupational therapy 
evaluations/services on this date. 
 
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 $25 
copayment for each Medicare-covered physical, occupational, and speech language therapy visit. You have been asked to pay a $25 copayment for the physical therapy visit and a $25 copayment for the 
occupational therapy visit. 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 the physical and 
occupational therapy services (97165, 97161) provided on September 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visits provided from March 
29, 2021, to October 18, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visits. You say that the services should be 
covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 
provided. 
 
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 $35 
copayment for Physician/Practitioner services, including doctor's office visits.  
 
 
 
 You have been asked to pay a $105 copayment for three specialist office visits ($35 x 3 = $105). Specialist 
office visits fall within the Physician/Practitioner services, including doctor's office visits benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for specialist office visits provided from March 29, 2021, to 
October 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (70544) provided on August 26, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service.  
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 70544 
is a column II code to column I code 70553. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the services (70544) provided on August 26, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from September 12, 2021, to October 11, 2021. 
 You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says this could have been rendered at a lower level of care. 
 
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 pay for the services. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. The enrollee did not require skilled 
nursing or therapy services on a daily basis. The enrollee did not meet severity of illness or intensity of service 
criteria for an inpatient basis in a skilled nursing facility 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee from September 12, 2021, to 
October 11, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on 
August 31, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must 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 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 out of network medical services provided to the 
enrollee on August 31, 2021.