Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric services from January 
28, 2022, forward. 
 
You asked the Plan to pre-approve continued inpatient psychiatric services. You say that the enrollee requires 
inpatient psychiatric care. The Plan denied your request. The Plan says based on Medicare guidelines, the 
requested Mental Health Inpatient Psychiatric services do not meet the requirements for approval beginning 
January 28, 2022. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.   
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 continued inpatient psychiatric services. 
Our reviewer says that the continued inpatient psychiatric admission from January 28, 2022, forward is 
medically necessary and reasonable in this case. Our physician reviewer found that you did appear to require 
inpatient mental health treatment beyond the date in question as you were unable to care for yourself and were 
not compliant with treatment. It did appear that active treatment was taking place beyond the date in question. 
It did appear that the services were reasonably expected to improve your condition or for the purpose of 
diagnosis beyond the date in question. It did appear that the records were supervised and evaluated by a 
physician. Based upon review the records provided for your admission does meet the criteria for continued 
acute inpatient mental health treatment for the dates in question of January 28, 2022, forward as although you 
were not shown to be a danger to yourself or others, you were not compliant with treatment, remain delusional, 
psychotic and resistant to treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient psychiatric services have been met. Therefore, we decided 
that the Plan does not have to pre-approve continued inpatient psychiatric services from January 28, 2022, 
forward.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder surgery services provided on December 2, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the code is 
not supported in the documentation. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 In this case, the CPT Code Manual definition of code 29806 is Arthroscopy, shoulder, surgical; 
capsulorrhaphy. We looked at the file and the rules. The medical records provided do not show that the service 
billed with the -59 modifier is a distinct procedural service. The billed code does not represent a different 
session or patient encounter, different procedure or surgery, different site, or organ system, separate 
incision/excision, or separate injury. Based on this information, we decided that Medicare rules for coverage of 
services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay 
for the shoulder surgery services provided on December 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services rendered on January 27, 
2021, to January 29, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim has not been processed by the primary insurer. 
 
 The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has confirmed 
that they have not received an Explanation of Benefits (EOB) from the primary insurance for this claim. As the 
secondary insurer, the Plan cannot be held responsible for these services until the primary insurer has denied 
the claim for these services. Therefore, we decided that the Plan does not have to pay for the outpatient hospital 
services rendered on January 27, 2021, to January 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Erbitux for the enrollee. 
 
You asked the Plan to pre-approve Erbitux. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the clinical value and effectiveness of cetuximab in the setting of metastatic primary 
gastroesophageal junction adenocarcinoma has not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Erbitux. Our reviewer says that Erbitux 
is not medically reasonable and necessary. Erbitux is not FDA-approved for the enrollees diagnosis. The use 
of Erbitux is not supported by one of the major drug compendia or by clinical research that appears in a CMS-
approved medical journal. Our physician reviewer found that the enrollee's condition does not meet criteria for 
coverage of Erbitux. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Erbitux have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Erbitux for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom myoelectric elbow- wrist-hand-finger orthosis, 
the MyoPro2 Motion G (L8702 ). 
 
You asked the Plan to pre-approve the MyoPro 2. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item 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 the MyoPro 2. Our reviewer says that 
the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the requested device has not been shown to be superior to other standard treatments for the medical 
condition.  The studies do not indicate the MyoPro brace improves an individuals function or general health. 
 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 MyoPro 2 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a custom myoelectric elbow- wrist-hand-finger orthosis, the MyoPro2 Motion G (L8702 ).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twelve (12) additional PT visits. 
 
You asked the Plan to pre-approve twelve (12) additional PT visits. You say that additional PT is medically 
necessary. The Plan denied your request. The Plan says additional PT is not medically 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 twelve (12) additional PT 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 that the additional requested therapy 
generally is not accepted as specific and effective therapy for your condition beyond what was approved by the 
Plan. You have had prior therapy and the documentation does not reveal that you require the unique skills of a 
professional therapist to safely and effectively provide treatment, or that the services can be safely and 
effectively performed only by a therapist, or by or under the supervision of a therapist. Your deficits and 
functional level do not require ongoing skills of a professional PT.  The requested services are not part of a 
maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required 
to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further 
deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of twelve (12) additional PT visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve twelve (12) additional PT visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 6, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on October 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron, 4mg tablets. 
 
You asked the Plan to pre-approve Ondansetron, 4mg tablets. You say that the reason for your prescription was 
to help regain your appetite back as well as being lightheaded. You say that this prescription lasted for four 
days before going to urgent care and you were unable to get this prescription when you really need it. The Plan 
denied your request. The Plan says this medication falls under Part D coverage. 
 
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 Ondansetron, 4mg tablets.  
  Benefits for Ondansetron, 4mg tablets 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the out-of-network office visit. You say that you would like reconsideration 
because you would like a second opinion from a qualified doctor. The Plan denied your request. The Plan says 
there are in-network providers available who may render the necessary services. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the office visit to be provided 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 an office visit provided on April 14, 2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that you were told your primary care 
physician (PCP) was in-network by customer service and there should be no copayment. The Plan denied your 
request. The Plan says the PCP did not become a participating provider until May 1, 2021, which is after the 
date of service. Therefore, the proper copayment for an out-of-network provider was applied. 
 
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 $40 
copayment for Out-of-Network Medicare-covered primary care doctor visit.  
 
  You have been asked to pay a $40 copayment for the office visit. The office visit falls within the 
Physician/Practitioner services, including doctors 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 an office visit provided on April 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and vision services provided on May 6, 2021. 
 
You asked the Plan to pay for an office visit and vision services. The Plan denied your request. The Plan says 
prior authorization was not obtained by the provider. 
 
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 
services at issue. 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 an office visit and vision services provided on May 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate artery embolization. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered experimental, investigational, unproven, and therefore, not covered by 
the plan. 
 
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 the record indicates that the enrollee has benign prostatic hypertrophy with lower urinary tract 
symptoms. The American Urological Association has stated that the requested service is not recommended 
outside the context of clinical trial. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve prostate artery embolization.
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 inpatient rehabilitation is medically necessary for 
this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The 
enrollee's care needs can be met in an alternate setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
documentation does support a need for physical and/or occupational therapy, there is no documented need for 
an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional Modivcare mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that you need transportation to and from your 
hip replacement surgery. You also say you understand the Plan covers up to 50 miles, but you are asking the 
Plan to assist by approving the additional 11 miles. The Plan denied your request. The Plan says you are 
requesting an additional 11 miles for a total of 61 miles and your benefit only allows 50 miles. The Plan also 
says you have exceeded your benefit limit. 
 
 
 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers up to 24 one-way trips and each one-way trip must not exceed 50 miles of driving 
distance.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, trips over 50 miles 
are not covered. Therefore, we decided that the Plan does not have to pre-approve additional Modivcare 
mileage (A0170).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete abdominal ultrasound (76700) provided on 
September 17, 2021. 
 
You asked the Plan to pay for the ultrasound. You say that this is not a bundled service and should be paid. The 
Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to Procedure 
(PTP) edit exists between 93976 and 76700. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP code edit. 
This service was not billed as required by Medicare coding regulations. 
 
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 76700 
is a column II code to column I code 93976. 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 complete abdominal ultrasound (76700) provided on 
September 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek Guide test strips. 
 
You asked the Plan to pre-approve Accu-Chek Guide test strips. You say that these are medically necessary. 
The Plan denied your request. The Plan says that you have not tried to preferred products. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician or treating practitioner must 
document in the beneficiarys medical record the reason why the specific brand or mode of delivery is 
necessary to avoid an adverse medical outcome. 
 
We looked at the file and Medicare rules. The file does not include any documentation from your physician 
documenting why you require this specific brand of test strips. Without this, medical necessity cannot be 
established. Therefore, we decided that the Plan does not have to pre-approve Accu-Chek Guide test strips.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram provided on August 7, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says an 
appropriate modifier was not billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
The file shows that CPT code 93010 was billed with CPT code 31500. We find that CPT code 93010 may be 
eligible for payment when billed with this code pair. The claim information does not show that the code at 
issue was billed with a modifier suitable for payment. Based on this information, we decided that Medicare 
rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for the electrocardiogram provided on August 7, 2021.