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

We decided that the Plan has to pre-approveMagnetic Resonance Imaging (MRI) of the Lumbar Spine (72148).You asked the Plan to pre-approvethe MRI. You say that the MRI is medically necessary.The Plan denied your request. The Plan says that coverage criteria has not been met.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 the MRI is medically necessary. Our physician reviewer found the enrollee has persistent back pain with radiation. The MRI is needed for diagnostic.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 been met.Therefore, we decided that the Plan has to pre-approveMagnetic Resonance Imaging (MRI) of the Lumbar Spine (72148).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 toopen 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 central venous catheter placement provided on January 
31, 2020. 
 
You asked the Plan to pay for the catheter placement. You say that this was denied due to the procedure code 
being included in payment of other services which is not appropriate in this case. The Plan denied your request. 
The Plan says the denial was due to an inappropriate diagnosis code being listed as primary. 
 
The Plan must follow Medicare rules. Medicare rules say that certain diagnosis codes have a note of "Code 
First" in the ICD-10 manual which indicates that it is a manifestation code which should not be used as a 
primary diagnosis. The underlying condition should be reported first.  
 
In this case, the reported primary diagnosis code F05, Delirium due to known physiological condition, has a 
Code First note. The underlying condition was not reported and should be reported before F05. Therefore, we 
decided that the Plan does not have to pay for the central venous catheter placement provided on January 31, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation provided on June 8, 2020. 
 
You asked the Plan to pay for the limited oral evaluation. You say that you went for an evaluation to 
understand your options for repair. You say that you expect insurance to cover the evaluation of damage and 
assessment of options. The Plan denied your request. The Plan says oral evaluations are limited to one every 6 
months. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of 
one exam every 6 months. The Plan paid for an oral exam provided on March 3, 2020, which exhausted your 
benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation provided on 
June 8, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a myoelectric prosthetic (L8702). 
 
You asked the Plan to pre-approve the myoelectric prosthetic. You say that the MyoPro device is medically 
necessary. The Plan denied your request. The Plan says that this item is 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 the myoelectric prosthetic. Our 
reviewer says that the requested item is considered medically reasonable and necessary in this case. Our 
physician reviewer found current evidence supports the benefit of myoelectric prosthetic devices in the setting 
of permanent paresis of extremities compared to first line treatment options. This patient has failed first line 
treatments and would clearly benefit from the MyoPro device to help them with daily activities, requiring less 
assistance. 
 
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 myoelectric prosthetic have been met. Therefore, we decided that the Plan 
has to pre-approve a myoelectric prosthetic (L8702).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services coded 73560 provided on August 14, 
2019. 
 
You asked the Plan to pay for the x-ray 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 a duplicate. 
 
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 73560 is radiologic examination, knee; 1 or 2 views. 
 
We find that CPT code 73560 is not supported in the medical record. Specifically, this claim is an exact 
duplicate service and claim to a previously processed and paid claim. Based on this information, we decided 
that Medicare rules for coverage of the x-ray services have not been met. Therefore, we decided that the Plan 
does not have to pay for the x-ray services coded 73560 provided on August 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for photochemotherapy sessions (96910) 
received on April 27 to July 2, 2020. 
 
You asked the Plan to waive the copayment for photochemotherapy sessions. You say that you do not see the 
doctor during these services. The Plan denied your request. The Plan says the correct copayment was applied. 
 
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 consultation, diagnosis, and treatment by a specialist.  
 
You have been asked to pay a $40 copayment for photochemotherapy sessions. Photochemotherapy sessions 
fall within the "Physician/Practitioner services, including doctor's office visits" 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 photochemotherapy sessions (96910) received on April 27 to July 2, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network outpatient mental health care provided to the 
enrollee on January 20, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network mental health care. 
 
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 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 out of network outpatient 
mental health care provided to the enrollee on January 20, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit (99285) provided on January 
30, 2020. 
 
You asked the Plan to pay for the emergency department visit. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the documentation does not 
support the level of the service billed. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function.  
 
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 the emergency department visit. Our reviewer says that CPT 
code 99285 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical 
records provided to not include documentation to meet the level code description that is used for CPT code 
99285, therefore this service 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 emergency department visit have not been met. Therefore, we decided that 
the Plan does not have to pay for the emergency department visit (99285) provided on January 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crutch substitute, lower leg platform, with or without 
wheels, each (CPT Code E0118). 
 
You asked the Plan to pre-approve the crutch substitute. You say that you will be having ankle surgery and 
your doctor has prescribed for you to use a knee scooter for recovery. The Plan denied your request. The Plan 
 
 
says there is insufficient published clinical literature demonstrating safety and effectiveness in the Medicare 
population to establish the medical necessity for these products. 
 
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 crutch substitute. Our physician 
reviewer found based on review of the available records, the patient does not meet the criteria for coverage for 
the requested items. There is no supportive documentation for the requested item indicating it was either 
recommended or prescribed by the physician. The medical records provided do not meet the requirements 
listed in the LCD for Medicare coverage. 
 
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 crutch substitute have not been met. Therefore, we decided that the Plan 
does not have to pre-approve crutch substitute, lower leg platform, with or without wheels, each (CPT Code 
E0118).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a pacemaker programming evaluation 
(93280) performed on May 15, 2020. 
 
You asked the Plan to waive the copayment for a pacemaker programming evaluation. You say that you think 
you shouldn't be charged the office visit copayment for this service. The Plan denied your request. The Plan 
says the correct copayment was applied. 
 
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 $35 
copayment for consultation, diagnosis, and treatment by a specialist.  
 
You have been asked to pay a $35 copayment for a pacemaker programming evaluation. A pacemaker 
programming evaluation falls within the "Physician/Practitioner services, including doctor?s office visits" 
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 a pacemaker programming 
evaluation (93280) performed on May 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a stair lift. 
 
You asked the Plan to pay for a stair lift. You say that you are unable to claim the stairs in your multi-level 
home, due to poor health. You say that you need the stair lift to get from one floor to the other. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pay for a stair lift.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gradient compression stockings (CPT Code A6530). 
 
You asked the Plan to pre-approve the compression stockings. You say that you need the socks for circulation 
and underlying health issues. The Plan denied your request. The Plan says the records show that you have 
diabetes and nerve problems from diabetes (diabetic neuropathy). The Plan states the specialized stockings 
(A6530) that you request are not covered by Medicare. The Plan states other types of compression stockings 
may be approved by Medicare for the treatment of an open ulcer. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the compression stockings have not been met. Your medical 
records do not show that you have open wounds (ulcers) on your legs. Since you do not meet the Medicare 
guidelines, we are not able to approve the request. Therefore, we decided that the Plan does not have to pre-
approve gradient compression stockings (CPT Code A6530).
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 your nursing, medical and rehabilitation needs do not require an 
acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is not a 
reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an inpatient rehabilitation facility. You continue to have a need for skilled therapy 
with ongoing safety concerns and a potential for functional improvement however, the documentation doesn't 
support that you would meet criteria for admission to an acute inpatient rehabilitation facility. There is no 
indication that you would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a 
week, under the supervision of a physician with at least 3 visits weekly to regain or maintain your functional 
status. You are ambulating up to 100 feet with a rolling walker and supervision. You are near your prior level 
of function and could receive services at a lower level of care. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of an abdominal ultrasound provided on 
January 30, 2020. 
 
You asked the Plan to pay for the ultrasound interpretation. You say that this is not a duplicate claim and 
should be paid. The Plan denied your request. The Plan says payment was already made for this service to this 
physician and there is no evidence that more than one service was provided. 
 
The Plan must follow Medicare rules. Medicare rules say that exact duplicate claims will be denied.  
 
In this case, the Plan shows that a claim for this service was received on February 18, 2020 and paid on 
February 23. An exact duplicate claim was then received on May 24, 2020 and denied on May 27. The appeal 
documentation does not include any evidence to show that the provider reviewed more than one ultrasound test 
on this date of service. The denial as a duplicate claim is supported. Therefore, we decided that the Plan does 
not have to pay for the interpretation of an abdominal ultrasound provided on January 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ultrasound provided on May 14, 2020.You asked the Plan to waive the copayment foran ultrasound. You say that you disagree with the charges because the test was not necessary.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $110 copayment for ultrasounds. You have been asked to pay the allowed amount of $83.07, which is less than the$110 copaymentfor an ultrasound. An ultrasound falls 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 foran ultrasound provided on May 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0428 and A0425) provided on 
October 5, 2019. 
 
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration because the 
services rendered were medically necessary. The Plan denied your request. The Plan says the diagnosis codes 
reported are mismatched. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that the ambulance services are not supported in the record. Specifically, the claim has been billed 
with a diagnosis code indicating the left femur and a diagnosis code indicating an unspecified femur. Based on 
this information, we decided that Medicare rules for coverage of the ambulance services have not been met. 
Therefore, we decided that the Plan does not have to pay for ambulance services (A0428 and A0425) provided 
on October 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care services provided by a 
participating provider on March 31, 2020. 
 
You asked the Plan to waive the copayment for urgent care services. You say that this was for Covid-19 
testing. The Plan denied your request. The Plan says the member did not receive Covid-19 testing services. 
 
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 urgently needed services.  
 
You have been asked to pay a $45 copayment for urgent care services. Urgent care services fall within the 
urgently needed 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 urgent care 
services provided by a participating provider on March 31, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a drug test provided on November 20, 2019. 
 
You asked the Plan to pay for the drug test. 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 
drug test. 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 drug test provided on November 20, 2019.