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

 
We decided that the Plan does not have to pre-approve revascularization surgery. 
 
You asked the Plan to pre-approve the requested surgery. You say that this surgery is medically necessary. The 
Plan denied your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. Medicare has specific coverage criteria for this type of surgery. 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 surgery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the request is for Endovascular Revascularization (Open or Percutaneous, 
Transcatheter) Procedures (CPT 372343). The medical records show a diagnosis of Type 2 diabetes mellitus 
with diabetic peripheral angiopathy without gangrene, as well as neuropathy, COPD, heart disease, 
hypertension, and chronic kidney disease. On August 28, 2020, it is documented that you were smoking 10 
cigarettes per day. The records show the glucose is uncontrolled. An Ankle Brachial Index Assessment on the 
same day was abnormal. On September 3, 2020 you had an office consultation for peripheral vascular disease. 
Findings suggested significant right iliac and femoral disease. However, while the records show you are taking 
a statin drug, the medical records do not document a course of antiplatelet therapy, a home exercise program, 
and smoking cessation including planning, counseling or behavior modification and pharmacotherapy if 
needed. Therefore, Medicare criteria for the requested surgery 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 requested surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve revascularization surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit (99213) with an 
ophthalmologist on May 12, 2020. 
 
You asked the Plan to waive the copayment for an office visit. You say that you should not be charged because 
there was a long wait. The Plan denied your request. The Plan says this 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 $30 
copayment for each Medicare-covered specialist office visit.  
 
You have been asked to pay a $30 copayment for an office visit with an ophthalmologist, which is a specialist. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an office visit (99213) with an ophthalmologist on May 12, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring 
provided on September 9, 2019. 
 
You asked the Plan to pay for intraoperative neuromonitoring. You say that your services were requested out of 
medical necessity by the treating surgeon. The Plan denied your request. The Plan says the denial of payment 
for this service is correct, because this code is not valid for Medicare purposes and is not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure code 95941 is not valid for Medicare 
purposes and is not payable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of intraoperative neuromonitoring have not been met. Therefore, we decided that the Plan does not 
have to pay for continuous intraoperative neurophysiology monitoring provided on September 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis (L3960) and 
neuromuscular stimulator (E0745) provided on April 10, 2020. 
 
You asked the Plan to pay for the orthosis and stimulator. You say that you would like reconsideration because 
these supplies are medically necessary. The Plan denied your request. The Plan says the documentation 
indicates that these supplies are not necessary for the treatment of the member'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 the shoulder elbow wrist 
hand orthosis (L3960) and neuromuscular stimulator (E0745) provided on April 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 66982) provided on January 29, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot 
be verified. 
 
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 66982 is "Extracapsular cataract removal with insertion 
of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration 
or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract 
surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or 
performed on patients in the amblyogenic developmental stage; without endoscopic cyclophotocoagulation". 
 
We asked our coding 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 use 
of CPT code 66982 is not supported by the records provided. Our coding reviewer found that the operative 
report did not include documentation to support CPT 66982. A more appropriate code should be used to 
support operative report. 
 
We looked at this coder'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 pay for the services (CPT 66982) provided on January 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination, knee; 3 views (73562) provided 
December 14, 2019. 
 
You asked the Plan to pay for radiologic examination. You say that the medical records attached will justify all 
3 key required components were met per CPT guidelines. Documentation completely validates the level of 
service billed for this emergency room charge. The Plan denied your request. The Plan says the records 
provided do not support the billed service. 
 
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 73562 is radiologic examination, knee; 3 views. 
 
We find that CPT code 73562 is not supported in the medical record. Specifically, the documentation submitted 
does not indicate that radiologic examination, knee; 3 views was performed. There is a more appropriate code 
73560 for 1 or 2 views. Based on this information, we decided that Medicare rules for coverage of radiologic 
examination have not been met. Therefore, we decided that the Plan does not have to pay for radiologic 
examination, knee; 3 views (73562) provided December 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a TTE with contrast, real-time with image documentation (2D), spectral doppler echocardiography, and with color flow doppler echocardiography provided on June 12, 2020.

You asked the Plan to pay for the TTE with contrast, real-time with image documentation (2D), spectral doppler echocardiography, and with color flow doppler echocardiography. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.

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 a TTE with contrast, real-time with image documentation (2D), spectral doppler echocardiography, and with color flow doppler echocardiography provided on June 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397, 
L2385) provided to the enrollee on April 10, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says there is no itemized billing/shipping invoice to verify the services billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a proof of delivery to support medical necessity for the supplies provided in this 
case. There is no itemized billing/shipping invoice to verify the services billed. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397, L2385) provided to the 
enrollee on April 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 11921) provided on March 3, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 11921 is "Tattooing, intradermal introduction of 
insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm". 
 
We asked our coding 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 use 
of CPT code 11921 is not supported by the records provided. Our coding reviewer found that the medical 
records provided do not include the size of the area tattooed, therefore the services cannot be verified. 
 
We looked at this coder'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 pay for the services (CPT 11921) provided on March 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the epidural neurostimulator. 
 
You asked the Plan to pre-approve the neurostimulator. You say that you would like reconsideration because 
this service is medically necessary. The Plan denied your request. The Plan says this service is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the neurostimulator. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you have several other conservative therapies that have not been trialed or an 
accepted indication for spinal cord stimulation. 
 
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 neurostimulator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the epidural neurostimulator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided March 31, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the records provided should support the necessity of 
the service in dispute. The Plan denied your request. The Plan says the records do not support the service 
billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery, itemized shipping/billing invoice or relevant medical 
records which support medical necessity for the supplies provided in this case. The documentation submitted 
did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery for the 
billed date of service.  The submitted invoice indicates the item was shipped on 03/26/2020 and delivered on 
03/28/2020 however, the billed date of service is 03/31/2020. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for lumbar-sacral orthosis (L0650) provided March 31, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on February 16, 
2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 16, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on 
February 16, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on March 13, 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 are not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of 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 Guardant360 panel rendered on March 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on February 8, 
2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 8, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on 
February 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient visit with injections of lower or sacral spine facet 
joint (64493,64494, 64495, 99214) provided on March 20, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the office or other outpatient visit with injections of lower or sacral spine facet 
joint. You say that you were given incorrect insurance information to request prior authorization. The Plan 
denied your request. The Plan says prior authorization was not obtained by the facility or the provider; 
therefore, payment has been correctly denied. 
 
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 outpatient visit with injections of lower or sacral 
spine facet joint (64493,64494, 64495, 99214) provided on March 20, 2019 by an out of network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for knee orthosis (L1851), a suspension sleeve (L2397) and a 
straight knee joint (L2385) provided on April 15, 2020. 
 
You asked the Plan to pay for the knee orthosis, suspension sleeve and straight knee joint. You say that you 
would like reconsideration because these supplies are medically necessary. The Plan denied your request. The 
Plan says the submitted documentation did not include an itemized billing/shipping invoice to indicate the 
specific supplies or proof of delivery for the billed items. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the 
record does not include an itemized billing/shipping invoice to verify the billed supplies. Additionally, the 
documentation submitted does not include a proof of delivery for the billed date of service. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for knee orthosis (L1851), a suspension sleeve (L2397) and a 
straight knee joint (L2385) provided on April 15, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five further home health skilled nursing visits. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says three visits are approved and five further are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records show that you do 
not have complex wound care needs and do not require the skills of a professional nurse for ongoing care. 
Skilled nursing services are not required to effectively provide treatment, care, and/or services in order to 
improve your condition, or to establish/perform a maintenance program to maintain your condition and/or 
prevent deterioration. The five further visits are 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve five further home health skilled nursing visits.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency department visit (99283) 
provided on June 10, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service 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 $90 
copayment for Medicare-covered emergency room visits.  
 
You have been asked to pay a $90 copayment for the emergency room visit provided. 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 department visit (99283) provided on June 10, 2020.