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

 
We decided that the Plan does not have to pre-approve bone marrow aspirate services. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is in severe pain and unable 
to stand. The Plan denied your request. The Plan says the clinical value in the setting of spinal fusion surgery 
has not been demonstrated. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
The file shows that bone marrow aspirate services during approved lumbar decompression and fusion surgery 
were requested. 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 requested 
services. Our physician reviewer found that Bone marrow aspirate is experimental. More research is needed 
when used as bone graft material in spinal surgery. Therefore, the request is not reasonable or 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate services.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the ophthalmic biometry and corneal topography. We decided that the 
Plan does not have to fully pay for the office visit or pay for the refraction.  
 
You asked the Plan to pay for the ophthalmic biometry, corneal topography, office visit and refraction. You say 
that you agreed to pay because it was your understanding that the doctors fee was covered by the Plan. You say 
that the charges are outside of the scope of your financial obligation to the doctor, and you should be 
reimbursed for the charges. The Plan says that the ophthalmic biometry and corneal topography are non-
covered benefits. The Plan also says the copayment applied correctly to the office visit and a refraction is only 
covered with a routine eye exam. 
 
We decided that the Plan has to pay for the ophthalmic biometry and corneal topography.  
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not forwarded any evidence or rationale to support 
their denial of these services. The ophthalmic biometry and corneal topography are considered Medicare 
covered diagnostic services. It is the burden of the Health Plan to substantiate their denial with evidence. In this 
case, the denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan 
has to pay for the ophthalmic biometry and corneal topography.  
 
We also decided that the Plan does not have to fully pay for the office visit or pay for the refraction. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. The 
Evidence of Coverage clearly states that you pay a $25 copayment for Medicare-covered vision services at a 
specialist's office. The records show a routine eye exam was not performed for the refraction to be covered. 
Therefore, we decided that the Plan does not have to fully pay for the office visit or pay for the refraction. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on September 4, 2021. 
 
You asked the Plan to pay for the services provided. You say that the specimens are received from providers 
and are irreplaceable. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
 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. The claim in this case was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. 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 lab services provided on September 4, 2021.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says that you have used all 24 one-way trips for 
the 2022 benefit year and additional trips will not be provided. 
 
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 did not provide a copy of the applicable trip record for this case. 
Without this information we cannot determine that the enrollee's routine transportation benefit has been 
exhausted. Therefore, we decided that the Plan has to pre-approve additional routine transportation.  
 
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 continued inpatient hospital care, May 5, 2022, forward. 
 
You asked the Plan to pre-approve continued inpatient care. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the continued care 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 continued inpatient care. Our reviewer 
says that the requested continued inpatient care is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the provided documentation does not indicate that the enrollee requires no 
inpatient diagnostic studies or therapeutic interventions. Therefore, the reviewer found that inpatient hospital 
level of care services after May 5, 2022, are not medically necessary or reasonable. 
 
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 care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued inpatient hospital care, May 5, 2022, forward.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99285) provided December 
13, 2021. 
 
You asked the Plan to pay for the emergency visit. You say that you are appealing the emergency room 
downgrade. You billed CPT code 99285 and was expecting a payment of $630.76. The Plan instead paid for 
CPT code 99284 and paid $439.43; a variance of $191.32. The Plan denied your request. The Plan says the 
procedure code was added/changed because it more accurately describes the services rendered. 
 
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect 
the services provided.   
 
In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the 
evaluation and management of a patient which requires three components (taking into account the urgency of 
the clinical condition or the patient's mental status): 
 
1. a comprehensive history; 2. a comprehensive examination; and 
3. medical decision making of high complexity. 
 
In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate 
significant threat to life or physiologic function.  
 
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 emergency visit Our reviewer says that 
the criteria for the emergency department visit 99285 level of coverage were not met. Our reviewer found the 
documentation submitted was reviewed, and the emergency department visit does not support level 99285. The 
documentation supports History: expanded problem focused; Exam: comprehensive; and MDM: moderate 
complexity. In this case, the documentation supports level 99383. 
 
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 emergency visit have not been met. Therefore, we decided that the Plan 
does not have to pay for the emergency department visit (99285) provided December 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81225, 81226, 81227, 81231, 
81238, 81240, and 81241 provided on December 8, 2021. 
 You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not separately payable. 
 
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 codes 
81225, 81226, 81227, 81231, 81238, 81240, and 81241 are column II codes to column I code 81413. 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 
laboratory services coded 81225, 81226, 81227, 81231, 81238, 81240, and 81241 provided on December 8, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction provided on January 4, 2022 by an 
ophthalmologist. 
 
  You asked the Plan to pay for the eye refraction. You say that the doctor should not have provided the service 
if it was not going to be covered. You also say that your insurance should have paid for the service. The Plan 
denied your request. The Plan says you were seen by a specialist, and this was not for a routine exam with an 
optometrist. The Plan also says that you signed a consent form acknowledging the service was not covered and 
a $45 payment was due at the time of service. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the refraction is performed as part of a routine vision eye exam 
by an optometrist. 
 
We looked at the file and the Plan's rules. Specifically, you received the eye refraction from an 
ophthalmologist. The record also shows that you signed a consent with the provider acknowledging the eye 
refraction would not be covered, and you would be responsible for the bill. Based on this information, we 
decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that 
the Plan does not have to pay for the eye refraction provided on January 4, 2022 by an ophthalmologist.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a spermatic cord lipoma excision billed with code 55559 for 
date of service October 4, 2021. 
 
You asked the Plan to pay for a spermatic cord lipoma excision. You say that the requested services were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not 
been met because the CPT code at issue is inclusive to another billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 55559 is "Unlisted laparoscopy procedure, spermatic 
cord." 
 
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 a spermatic cord lipoma excision. Our reviewer says that the 
requested service does not meet criteria for reimbursement as billed. Our reviewer found that the procedure was reported with the incorrect CPT code. The available documentation describes right and left cord lipoma 
excision but is being reported with an unlisted CPT code. There is a more appropriate code to report this 
procedure and it would not be reported with an unlisted procedure code. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a spermatic cord lipoma excision have not been met. Therefore, we decided that 
the Plan does not have to pay for a spermatic cord lipoma excision billed with code 55559 for date of service 
October 4, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a psychiatric diagnostic evaluation with medical services (90792) 
provided on August 12, 2021. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that you would like 
reconsideration because these medically necessary services were rendered in good faith. The Plan denied your 
request. The Plan says that this is a duplicate claim. 
 
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. Specifically, the Plan has not forwarded any evidence that a claim for the same 
provider and same date of service has been processed and paid. It is the burden of the Health Plan to 
substantiate their denial with evidence. In this case, the denial has not been substantiated so we must find in 
your favor. Therefore, we decided that the Plan has to pay for a psychiatric diagnostic evaluation with medical 
services (90792) provided on August 12, 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 the observation services provided on August 17, 2021. 
 
You asked the Plan to pay for the services provided. You say that the claim has not been paid in full. The Plan 
denied your request. The Plan says the claim processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the Medicare allowed amount for the services at issue was applied to an enrollee deductible. A bill 
for assigned services is considered paid in full when the Medicare allowed amount is paid. Therefore, we 
decided that the Plan does not have to pay for the observation services provided on August 17, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for the physical therapy (PT) visits provided from September 27, 2021, to 
December 30, 2021. 
 
You asked the Plan to pay for the PT services. You say that you feel the enrollee required additional visits. The 
Plan denied your request. The Plan says that the PT visits were 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 pay for the PT services. Our reviewer says that the 
PT services were medically necessary. Our physician reviewer found the provided documentation addresses the 
complexity of the neurological injury that the enrollee had suffered. The reviewer found that the enrollee was 
undergoing modification to bracing in addition to therapeutic treatment which would require the professional 
skill of a therapist. Therefore, the reviewer found that the PT services were medically 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 PT services have been met. Therefore, we decided that the Plan has to pay 
for the physical therapy (PT) visits provided from September 27, 2021, to December 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo for the enrollee. 
 
You asked the Plan to pre-approve Opdivo. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the clinical value and effectiveness of Opdivo in the setting of stage IV squamous 
cell carcinoma of the parotid gland have 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 Opdivo. Our reviewer says that Opdivo 
is not medically reasonable and necessary. The enrollee has a diagnosis of metastatic stage IV squamous cell 
carcinoma of the parotid gland. The Food and Drug Administration has not stated that the requested drug is 
indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a 
supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature from 
Medicare approved cancer journals were submitted for review. Our physician reviewer found that the enrollee's 
condition does not meet criteria for Opdivo.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Opdivo for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Fine needle aspiration biopsy, including ultrasound guidance 
(10005) provided on August 11, 2021. 
 
You asked the Plan to pay for the surgical service. You say that the service should be covered. The Plan denied 
your request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible 
for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice 
is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before 
rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on August 5, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for Fine needle 
aspiration biopsy, including ultrasound guidance (10005) provided on August 11, 2021.
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 IRF care is medically necessary so you can regain 
your strength before you go back home. The Plan denied your request. The Plan says IRF care is not medically 
necessary and your needs can be met at a lower level of care such as in a skilled nursing facility, at home with 
supervision or at home with home health services. 
 
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 while you have a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program such as 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.