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

We decided that the Plan does not have to waive the copayment for ambulance services provided on May 27, 
2020, and June 1, 2020; skilled nursing facility care provided from June 1, 2020, to June 26, 2020; an 
emergency room visit provided on June 1, 2020; and oxygen equipment provided from June 26, 2020, to 
August 26, 2020. 
 
You asked the Plan to waive the copayment for ambulance services, skilled nursing facility care, an emergency 
room visit, and oxygen equipment. You say that you believed all copayments would be waived. The Plan 
denied your request. The Plan says these services processed correctly. 
 
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 $245 
copayment for ambulance services, a $0 copayment for days 1-20 and a $178 copayment per day for days 21-
100 of each skilled nursing facility stay, a $90 copayment for emergency care, and a a 20% coinsurance for 
durable medical equipment. 
 
You have been asked to pay a $245 copayment or the lesser allowed amount for ambulance services, a $1,780 
copayment for days 21 to 30 of skilled nursing facility care, a $90 copayment  for an emergency room visit, 
and a 20% coinsurance for oxygen equipment. 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 ambulance 
services provided on May 27, 2020, and June 1, 2020; skilled nursing facility care provided from June 1, 2020, 
to June 26, 2020; an emergency room visit provided on June 1, 2020; and oxygen equipment provided from 
June 26, 2020, to August 26, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve Intracept System and associated procedure.
You asked the Plan to pre-approve Intracept System and associated procedure. You say that you would like the
plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not
medically necessary.
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 pre-approve Intracept System and associated
procedure. Our reviewer says that the requested items/services are considered medically reasonable and
necessary in this case. Our physician reviewer found according to the FDA Indications for Use, The Intracept
Intraosseous Nerve Ablation System is intended to be used in conjunction with radiofrequency generators for
the ablation of basivertebral nerves of the L3 through S1 vertebrae for the relief of chronic low back pain of at
least six months duration that has not responded to at least six months of conservative care, and is also
accompanied by features consistent with Type 1 or Type 2 Modic changes on an MRI such as inflammation,
edema, vertebral endplate changes, disruption and fissuring of the endplate, vascularized fibrous tissues within
the adjacent marrow, hypointense signals (Type 1 Modic change), and changes to the vertebral body marrow
including replacement of normal bone marrow by fat, and hyperintense signals (Type 2 Modic change)
The enrollee has chronic low back pain that has not responded to at least six months of conservative care, and
has Type 1 Modic changes in the lumbar spine at the L4-5 level. The enrollee has failed epidural steroid
injections, medial branch blocks, and radiofrequency-type ablation, in addition to a course of conservative
treatment. There is sufficient evidence based support for the requested procedure. There has been sufficient
documented detailed comprehensive and reasonable treatment provided prior to this request. Therefore, the
enrollee meets criteria for the requested services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Intracept System and associated procedure have been met. Therefore, we
decided that the Plan has to pre-approve Intracept System and associated procedure.
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) services 
rendered on September 29, 2020 to September 30, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The 
Plan denied your request. The Plan says the copayment was applied correctly. 
 
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 $90 
copayment for in-network emergency services.  
 
Review of the file shows that you received ER services on September 29, 2020 to September 30, 2020. You 
have been asked to pay a $90 copayment for these services. These services fall within the in-network 
emergency services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room 
(ER) services rendered on September 29, 2020 to September 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre CGM. 
 
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for the 
requested CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, does not use insulin with at least three daily injections, and does not 
require frequent self-adjustment of insulin dosage based on blood glucose testing results. Based on this 
information, we decided that Medicare rules for coverage of a Freestyle Libre CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre CGM.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for CT Scan of the head (70450) provided on August 15, 2020. 
 
You asked the Plan to pay for the CT Scan. You say that you would like reconsideration because the member 
had multiple exams on the same date and this claim denied as a duplicate in error. The Plan denied your 
request. The Plan says that CPT code 70450 is a column II code to column I code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that MACs subject all line items for the same beneficiary, same NPI, and same date of service to 
NCCI edits. 
 
We find that CPT code 70450 is supported in the record. Specifically, CPT code 70450 was billed by a   
provider with a different NPI than that who billed the column I code. It is not appropriate to apply NCCI edits 
to claims billed with different NPIs. Based on this information, we decided that Medicare rules for coverage of 
the CT Scan have been met. Therefore, we decided that the Plan has to pay for CT Scan of the head (70450) 
provided on August 15, 2020.  
 
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 lab work provided on September 8, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan 
denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring 
provider is also out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for lab work provided on September 8, 2020 by an out 
of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the lumbar injection provided on 
September 22, 2020. 
 
You asked the Plan to reduce the copayment for the injection. You say that you had a shot like this last year 
and it was only a $40 copayment. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment per day for outpatient procedures and services, including but not limited to diagnostic and 
therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical 
center.  
 
You have been asked to pay a $250 copayment for the injection. The injection falls within the ?Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers? benefit 
category. The record shows the injection was give under fluoroscopic guidance which is considered a surgical 
procedure. 
 
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 reduce the copayment for the lumbar injection provided on September 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance (eg, proton) imaging 
(MRI) of the brain (70553), MRI of any joint of lower extremity (73721) and computed tomographic (CT) 
angiography of the neck provided on August 6, 2020, September 11, 2020 and September 18, 2020. 
 
You asked the Plan to waive the copayment for MRI and CT scans. You say that the services should be 
covered. The Plan denied your request. The Plan says the cost share was applied correctly. 
 
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 $275 
copay for each advanced imaging services for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay a $275 copay for each advanced imaging services for MRI and CT scans. These 
services 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 (eg, proton) imaging (MRI) of the brain 
(70553), MRI of any joint of lower extremity (73721) and computed tomographic (CT) angiography of the 
neck provided on August 6, 2020, September 11, 2020 and September 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for weakness and confusion. Medical conditions are stable. There are no medical needs requiring 
inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record documents a need for physical and occupational 
therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable 
expectation that this patient 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wireless capsule endoscopy (WCE) you had on July 28, 
2020. 
 
You asked the Plan to pay for the endoscopy. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a wireless capsule endoscopy is covered for the above 
indications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the endoscopy. Our reviewer says that the 
requested wireless capsule endoscopy was not medically reasonable and necessary. Our physician reviewer 
found that the available record does not support that an EGD or colonoscopy were recently performed prior to 
your wireless capsule endoscopy on July 28, 2020. As such, the coverage criteria are not 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 the endoscopy have not been met. Therefore, we decided that the Plan does not 
have to pay for the wireless capsule endoscopy (WCE) you had on July 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prolonged evaluation and management (99358) provided 
on May 25, 2020, through May 27, 2020. 
 
You asked the Plan to pay for the prolonged evaluation and management. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation 
submitted indicates that the prolonged time was spent coordinating care with other providers.  
 
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 99358 is prolonged evaluation and management service 
before and/or after direct patient care; first hour. 
 
We find that CPT code 99358 is not supported in the record. Specifically, the record indicates that the 
prolonged evaluation was spent coordinating care with other providers. There is a more appropriate CPT code 
for the services rendered. Based on this information, we decided that Medicare rules for coverage of the 
prolonged evaluation and management have not been met. Therefore, we decided that the Plan does not have to 
pay for the prolonged evaluation and management (99358) provided on May 25, 2020, through May 27, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dry pressure mattress and semi-electric hospital bed 
provided on August 6, 2020. 
 
You asked the Plan to pay for the dry pressure mattress and semi-electric hospital bed. You say that you 
believe this claim was denied in error. You also say that the enrollee was discharged from hospice on August 1, 
2020, 5 days before the medical equipment was delivered. The Plan denied your request. The Plan says your 
request for payment is the responsibility of Original Medicare. 
 
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 1, 2020. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the dry pressure 
mattress and semi-electric hospital bed provided on August 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on 
July 17, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis 
(L0650) provided to the enrollee on July 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services provided on February 19, 
2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
payable for this type of provider. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services 
provided on February 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on June 23, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that place of Service (POS) code 31 should be used 
with services for patients in a Part A covered stay and POS code 32 should be used with services for 
beneficiaries in a non-covered stay. Carriers should adjust their prepayment procedure edits as appropriate.  
 
We looked at the file and Medicare rules. As this was a non-covered stay, the services must be billed with POS 
32. The services were billed incorrectly with POS 31. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for the services provided on June 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the optometry services provided by an out of network 
provider on September 18, 2020. 
 
You asked the Plan to pay for the optometry services. You say that the provider is in network. The Plan denied 
your request. The Plan says you did not request prior authorization for the out of network services that were 
filed from an out of network group. 
 
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 optometry services provided by an out of 
network provider on September 18, 2020.