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

 
We decided that the Plan does not have to pre-approve bioimpedance spectroscopy (BIS), extracellular fluid 
analysis for lymphedema assessment(s) (CPT Code 93702). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says there is insufficient clinical evidence published in the peer-reviewed literature to 
establish efficacy for this device. 
 
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 items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the clinical documentation does not support that bioimpedance 
spectroscopy (BIS), extracellular fluid analysis is medically reasonable and necessary for the enrollee in this 
case. 
 
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 bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema 
assessment(s) (CPT Code 93702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the orthopedics consultation to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve an OON orthopedics consultation. You say that network providers have not 
determined why your knee replacement failed. The Plan denied your request. The Plan says you must receive 
care form network providers. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 an OON orthopedics consultation. Our reviewer says that the criteria for an 
OON orthopedics consultation have not been met. Our physician reviewer found there is no medical need for 
referral out of plan. There are there are total joint specialists in plan who are qualified to care for failed and 
revision total knee issues. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an OON orthopedics consultation have not been met.  
 
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 an OON orthopedics consultation. Therefore, we 
decided that the Plan does not have to pre-approve the orthopedics consultation to be provided by an out of 
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PureWick external catheter system. 
 
You asked the Plan to pre-approve these services. You say that you need the device. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve a PureWick external catheter 
system.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of the lumbar spine (72148). 
 
You asked the Plan to pre-approve the MRI. You say that you would like reconsideration because the member 
is experiencing increased pain and has not had any lumbar imaging. The Plan denied your request. The Plan 
says there is a lack of clinical documentation showing a failure to improve after 6 or more weeks of 
nonoperative treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 pre-approve the MRI. Our reviewer says that it is 
unclear from the office visit note provided what clinical benefit would be gained from the performance of MRI 
of the lumbar spine at this time. Our physician reviewer found the member's neurological exam was 
unremarkable. There were no findings on exam that suggested an acute compressive process involving the 
lumbar spine. The member was also not noted to have tried any form of therapy/treatment for his low back 
pain. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI of the lumbar spine (72148).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the vision services received on August 5, 
2020. 
 
You asked the Plan to waive the copayment for the vision services. You say that you thought that this was 
covered as preventive services for your eye exam. The Plan denied your request. The Plan says the claim has 
been processed correctly per your plan benefits. 
 
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 each Medicare-covered eye exam to diagnose and treat diseases and conditions of the eye.  
 
You have been asked to pay a $40 copayment for the vision services. The vision services fall within the vision 
benefit category. The documentation supports that the appointment received was not for routine care, but for a 
medical condition, Macular Degeneration. The services revived where therefore provided to treat diseases and 
conditions of the eye. 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 vision services received on 
August 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic office visit (99213), orthotics management 
(97763), and electrical stimulation (97032) provided on June 30, 2020. 
 
You asked the Plan to pay for a chiropractic office visit, orthotics management, and electrical stimulation. You 
say that you were told these services would not be denied. The Plan denied your request. The Plan says these 
services are not covered when provided by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for a chiropractic office visit (99213), orthotics management (97763), and 
electrical stimulation (97032) provided on June 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses purchased on August 6, 2020. 
 
You asked the Plan to pay for the vision services. You say that you had to get a new exam and which created a 
new prescription and is requesting reconsideration paying for the newer lenses. The Plan denied your request. 
The Plan says this request exceeds the benefit maximum. 
 
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 allows a vision hardware allowance up to $150 every year. You must pay any remaining 
balance. 
 
We looked at the file and the Plan's rules. The plan allows a vision hardware allowance up to $150 every year. 
You must pay any remaining balance. Based on this information, we decided that the Plan's rules for coverage 
 
 
of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for the 
eyeglasses purchased on August 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 14, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 subsequent nursing facility care provided on May 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the visit you had at your otolaryngologist's 
office on May 22, 2020. 
 
You asked the Plan to waive the copayment for the otolaryngology visit. You say that you went to the doctor's 
office to pick up your hearing aids.  You say that you didn't see the doctor, so your copayment should be 
waived.  You said that the nurse at the office said they would waive the copayment. The Plan denied your 
request. The Plan says you were charged this copayment correctly.  To date, the Plan has not received any 
corrected claims from the provider where they have agreed to waive this copayment. 
 
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 $45 
copayment for visits to a specialist's office.  
 
You have been asked to pay a $45 copayment for the otolaryngology visit. Please note that this copayment can 
apply even if you don't physically see the doctor. 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 visit you had at your otolaryngologist's office on May 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth services provided on August 25, 2020 by an 
out of network provider. 
 
You asked the Plan to pay for the telehealth services. You say that authorization should not be needed for 
telemedicine. The Plan denied your request. The Plan says you did not request prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. The Plan did not pre-approve the service 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 the telehealth services provided on August 25, 2020 by an out of network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic digital breast tomosynthesis (77062) provided on 
June 24, 2020. 
 
You asked the Plan to pay for the diagnostic digital breast tomosynthesis. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 77062 
has a status indicator of I which is not valid for Medicare purposes. 
 
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 77062 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code 77062 has a status indicator of I. This means that CPT code 77062 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the diagnostic digital breast 
tomosynthesis have not been met. Therefore, we decided that the Plan does not have to pay for diagnostic 
digital breast tomosynthesis (77062) provided on June 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Total Electric Hospital Bed 
 
You asked the Plan to pre-approve a Total Electric Hospital Bed. You say that you need a full-size bed because 
the hospital bed you have is not big enough. The Plan denied your request. The Plan says you already have a 
semi-electrical hospital bed. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a Total Electric 
Hospital Bed
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 4, 2020 to May 15, 
2020 by a non-network provider. 
 
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 rendered by a non-network provider without prior authorization. 
 
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 has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on May 4, 2020 to 
May 15, 2020 by a non-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services rendered on June 10, 2020. 
 
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 billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that when reporting an encounter/visit for payment, the 
FQHC must bill on the claim (77X TOB) a FQHC specific payment code of G0466, G0467, G0468, G0469, or 
G0470. 
 
We looked at the file and Medicare rules. The FQHC services were not billed with one of the required G codes. 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the services rendered on June 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for cardiology services for review and 
interpretation of home INR monitoring you received from February 26, 2019, to June 6, 2019. 
 
You asked the Plan to waive the copayments for the cardiology services. You say that you are on a fixed 
income and you cannot afford these charges. The Plan denied your request. The Plan says you were charged 
these copayments correctly.  The Plan says that since the allowed amount for these services ($8.94) is less than 
your copayment responsibility, you are responsible for the full 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 $45 
copayment for services obtained from a specialist.  
 
You have been asked to pay a $45 copayment for the cardiology services. The cardiology services fall within 
the services obtained from a specialist 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 
cardiology services for review and interpretation of home INR monitoring you received from February 26, 
2019, to June 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospitalist services provided on September 9, 2019. 
 
You asked the Plan to pay for Hospital discharge day management; more than 30 minutes (99239). You say 
that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation submitted 
does not indicate the time spent on discharge services. 
 
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 99239 is Hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the medical record does not 
show how much time was spent on the discharge service. Based on this information, we decided that Medicare 
rules for coverage of Hospital discharge day management; more than 30 minutes have not been met. Therefore, 
we decided that the Plan does not have to pay for hospitalist services provided on September 9, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services you received on July 24, 2020. 
 
You asked the Plan to waive the copayment for the lab services. You say that these lab services were part of 
your annual exam, so there should be no copayment. The Plan denied your request. The Plan says you were 
charged this copayment correctly.  The Plan says that because the allowed amount for these lab services is less 
than your copayment, you are responsible for the full 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 $25 
copayment for lab services.  
 
You have been asked to pay a $25 copayment for the lab services. Your Evidence of Coverage clearly states 
that additional cost sharing applies for tests you receive as part of your annual exam. 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 lab services you received on July 24, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy (PT) services you 
received from July 9, 2020, to July 19, 2020. 
 
You asked the Plan to waive the copayments for the PT services. You say that you received a letter saying that 
all copayments were being waived due to COVID-19. The Plan denied your request. The Plan says you were 
charged these copayments correctly.  The copayment waiver letter explicitly states only primary care and 
specialist physician visit copayments are being waived at this time. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment per visit for physical therapy services.  
 
You have been asked to pay a $20 copayment per visit for the PT services. 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 physical therapy (PT) services you received from July 9, 2020, to July 19, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for device interrogation services provided 
from February 3, 2020, to April 13, 2020. 
 
You asked the Plan to waive the copayments for the device interrogation services. You say that you believe 
these services are being charged as 'out-of-network' and that these copayments should be waived. The Plan 
denied your request. The Plan says these copayments were charged correctly.  You are not being charged for 
out-of-network services.  Rather, the appropriate cost sharing was applied for each date of service. 
 
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 non-radiological diagnostic services.  
 
You have been asked to pay a $25 copayment for each of the device interrogation services. The device 
interrogation services fall within the non-radiological diagnostic 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 copayments for device interrogation services provided from February 3, 2020, to 
April 13, 2020.