Persius/hicric huggingface dataset:
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 66-year-old female who was admitted to the acute care hospital 
with acute respiratory failure due to pneumothorax, requiring mechanical ventilation and trach placement, and 
3x chest tube placements. The patient appears to be more stable and improving and should only require short-
term additional acute care services that can be safely administered at the current facility until more stable and 
appropriate for a lower level of care. There are no services at the LTACH that the patient requires that are not 
already available and covered at the current facility. In conclusion, transfer to an LTACH is medically 
necessary at this time as it would not be clinically advantageous. Completion of treatment at the current acute 
care hospital 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive your cost-share amounts for the chemotherapy 
drugs/administration provided on January 20, 2022, February 17, 2022, and March 17, 2022. 
 
You asked the Plan to waive your cost-share amounts for chemotherapy drugs/administration on January 20, 
2022, February 17, 2022, and March 17, 2022. You say that you should not have to pay your co-insurance 
because you have reached your our-of-pocket maximum The Plan denied your request. The Plan says you pay 
20% of the total allowed amount for in-network Medicare covered Part B chemotherapy drugs and their 
administration. 
 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 20% of 
the total amount allowed for in-network Medicare covered Part B chemotherapy drugs and their administration.  
 
You have been asked to pay $1,761.79 for chemotherapy drugs/administration on January 20, 2022. The 
allowed amount for these services is $8,808.98. 20% of $8,808.98 is $1,761.79. You have been asked to pay 
the correct amount based on your contract with the Plan. You have been asked to pay $200 for the 
chemotherapy drugs/administration on February 17, 2022. The allowed amount for these services is $8,875.72. 
20% of $8,875.72 is $1,775.14. This means that you have been asked to pay less than your contracted amount 
for these services. You have been asked to pay $1,503.21 for the chemotherapy drugs/administration on March 
17, 2022. The allowed amount for these services is $8,808.98. 20% of $8,808.98 is $1,761.79. This means that 
you have been asked to pay less than your contracted coinsurance because you met your maximum out-of-
pocket with this claim. Chemotherapy drugs and their administration falls within the Medicare Part B 
Prescription Drugs benefit category. 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 your cost-share amounts for 
the chemotherapy drugs/administration provided on January 20, 2022, February 17, 2022, and March 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (CPT code G0483) provided on July 12, 
2021. 
 
You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the drug testing (CPT code G0483) provided on July 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428), and 
ground mileage (A0425) provided on November 8, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the ambulance services were not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same 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 pay for the ambulance services. Our reviewer says 
that the ambulance services were not medically necessary. Our physician reviewer found the provided 
documentation does not indicate that the enrollee was bedbound, as evidenced by their ability to complete a 
stand-pivot transfer. The reviewer found that the enrollee did not require the expertise of trained personnel or 
the equipment available only on an ambulance in order to effectuate a safe transport. The reviewer also found 
that transportation could have been provided by other means (stretcher van, wheelchair van) without 
endangering the enrollees condition. Therefore, the reviewer found that the ambulance services were 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 the ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the non-emergency ambulance transport (A0428), and ground mileage (A0425) 
provided on November 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular genetic testing provided on November 7, 
2021. 
 You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
screening test. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
cardiovascular genetic testing provided on November 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for overnight services (99053) provided on October 5, 2021. 
 
You asked the Plan to pay for overnight services. You say that you have provided records to support the service 
billed. 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. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of overnight services have not been met. Therefore, we decided that the Plan does not have to pay for overnight services (99053) provided on October 5, 
2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for group psychotherapy (other than of a multiple-family group) (CPT 
code 90853) provided from April 16, 2021, through April 30, 2021. 
 
You asked the Plan to pay for the services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that the requested service /procedure is not medically necessary and is not a 
standard of care for this enrollee. 
 
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 services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found it is noted that this enrollee is receiving telehealth treatment. The documentation shows that the 
enrollee did participate and was involved in therapy that was rendered. It is unclear how many patients were 
involved in each therapy session; however, the start and stop time was clearly documented along with the 
treatment goals. Based on review the records provided, this enrollee does meet the criteria for group 
psychotherapy as outlined based on LCD L34353 as being reasonable and medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
group psychotherapy (other than of a multiple-family group) (CPT code 90853) provided from April 16, 2021, 
through April 30, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260). 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the requested semi-electric 
hospital bed is not medically necessary. The Plan denied your request. The Plan says the rules for coverage 
have not been met. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or  
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that the requested semi-electric hospital bed is not medically reasonable and necessary. Our 
physician reviewer found the documentation does not support that you have a condition that requires frequent 
positioning of the bed and mattress to alleviate pain, promote good body alignment, prevent contractures or 
avoid respiratory infections in a way that an ordinary bed is not able to. 
 
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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed (E0260).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428) and ground 
mileage (A0425) provided on January 6, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the ambulance services were not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same 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 pay for the ambulance services. Our reviewer says 
that the ambulance services were not medically necessary. Our physician reviewer found the provided 
documentation does not indicate that the enrollee required the expertise of trained personnel or the equipment 
available only on an ambulance in order to effectuate a safe transport. The reviewer also found that the 
transportation could have been provided by other means (stretcher van, wheelchair van) without endangering 
the enrollees condition. Therefore, the reviewer found that the ambulance services were not medically 
necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the non-emergency ambulance transport (A0428) and ground mileage (A0425) 
provided on January 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 4, 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 services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on October 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthotic management and training (97760) provided on 
August 24, 2021. 
 
You asked the Plan to pay for orthotic management and training. You say that this service was medically 
necessary. The Plan denied your request. The Plan says this procedure needs to be billed with a therapy 
modifier in order to be eligible for payment. The Plan will accept a submission of a corrected claim to consider 
services with the missing information provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Codes 
considered to be always therapy codes must have one of the therapy modifiers appended (GN, GO, GP). 
 We find that CPT code 97760 is not supported as billed. Specifically, the Centers for Medicare and Medicaid 
Services has classified code 97760 as an always therapy code. This service was billed without the necessary 
therapy modifier appended. Based on this information, we decided that Medicare rules for coverage of orthotic 
management and training have not been met. Therefore, we decided that the Plan does not have to pay for 
orthotic management and training (97760) provided on August 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Magnetic resonance imaging (MRI) ( 
72158, 72156, 72157) provided on February 7, 2022, and February 11, 2022. 
 
You asked the Plan to waive the copayment for the MRIs. You say that the services should be covered as you 
disagree with the charges. 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 $15-
295 copayment for each outpatient diagnostic tests and therapeutic services and supplies, depending on the 
service.  
 You have been asked to pay a $518.22 copayment for two MRIs. MRIs fall within the Outpatient diagnostic 
tests and therapeutic services and supplies 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 Magnetic resonance imaging (MRI) (72158, 72156, 72157) provided on February 7, 2022, and February 11, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested viscosupplements device.  
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Euflexxa. Our reviewer says that 
Euflexxa is not medically reasonable and necessary. Our physician reviewer found the enrollee has not trialed 
one of the preferred viscosupplemental treatments such as, Orthovisc or Supartz FX. Step therapy, as outlined 
by the Plan, requires that one of these be trialed first. Our reviewer found that the documentation does not 
outline contraindications or reasons these medications were not considered or that the plans additional 
required drug would likely be less effective and/or likely have adverse effects for the enrollee. Our physician 
reviewer also found that without the support of the documentation, Euflexxa is not approved, as step criteria 
has not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs received on January 30, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you were given these medications by 
the nurse. You also say that you feel these drugs were mis-coded. The Plan denied your request. The Plan says 
the drugs received are 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 the self-administered drugs 
received on January 30, 2022.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment for the hearing test. We decided that the Plan does not 
have to waive the copayment for the office visit.  
 
You asked the Plan to waive the copayment for an office visit and hearing test. You say that you thought 
hearing tests were covered in a doctors office. The Plan says that the copayments applied is correct. 
 
  We decided that the Plan has to waive the copayment for the hearing test.  
 
The Plan says that a separate $10 copayment applies for the hearing test. We looked at your contract with the 
Plan. We did not see where the contract says enrollees must pay two copayments if an office visit and hearing 
test are performed during the same visit. The records do not support those separate visits were performed for 
two copayments to apply. The Evidence of Coverage clearly states the $10 copayment applies per visit. 
Therefore, we decided that the Plan must waive the $10 copayment for the hearing test.  
 
We also decided that the Plan does not have to waive the copayment for the office visit. 
 
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 $10 
copayment per visit to an in-network specialist for Medicare-covered services. Therefore, we decided that the 
Plan does not have to waive the $10 copayment for the office visit. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composites - one surface, posterior (D2391) 
provided June 1, 2021. 
 
You asked the Plan to pay for the resin-based fillings on your back teeth. You say that you were not told these 
services would not be covered. The Plan denied your request. The Plan says this service is not covered under 
your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-
based composites - one surface, posterior (D2391) provided June 1, 2021.