Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic intervention services (CPT 97129 and CPT 
97130) provided to the enrollee from June 1, 2020, to June 9, 2020. 
 
You asked the Plan to pay for the services. You say that this should be reconsidered. The Plan denied your 
request. The Plan says the claims were submitted without the appropriate modifier. 
 
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 the denied codes is: 
 
CPT 97129: 
 
Therapeutic interventions that focus on cognitive function (e.g., attention, memory, reasoning, executive 
functioning, problem solving and/or pragmatic functioning) and compensatory strategies to manage the 
performance of an activity (e.g., managing time or schedules, initiating, organizing, and sequencing tasks), 
direct (one-to-one) patient contact; initial 15 minutes 
 
CPT 97130: 
 
Therapeutic interventions that focus on cognitive function (e.g., attention, memory, reasoning, executive 
functioning, problem solving and/or pragmatic functioning) and compensatory strategies to manage the 
performance of an activity (e.g., managing time or schedules, initiating, organizing, and sequencing tasks), 
direct (one-to-one) patient contact; each additional 15 minutes 
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records.  
 
 
 
 
 
Our physician reviewer found while billing/time sheets have been submitted for review, no provider records 
have been submitted for review. Therefore, there is no evidence to support that the billed services were 
provided (97129, 97130), hat the services were provided by a speech therapist (GN) or that the services were 
medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition. 
 
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 pay for therapeutic intervention services (CPT 97129 and CPT 97130) provided to the enrollee from 
June 1, 2020, to June 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided out of network between 
November 29, 2018 and April 4, 2019. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says you did not have prior authorization for out of network 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 outpatient services provided 
out of network between November 29, 2018 and April 4, 2019.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound examination of heart (93306) provided on 
June 28, 2019. 
 
You asked the Plan to pay for the ultrasound examination of heart. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says the Medicare hospice 
benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date 
of discharge or revocation. 
 
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 June 10, 2019. 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 ultrasound examination 
of heart (93306) provided on June 28, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment charged for specialist services and imaging 
provided on June 2, 2020. 
 
You asked the Plan to waive this cost share. You say that this copayment is not correct. The Plan denied your 
request. The Plan says this copayment was charged based on the services 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 
copayment for outpatient diagnostic services in a specialist office. 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 
charged for specialist services and imaging provided on June 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $35 copayment charged for a specialist visit provided on 
July 17, 2020. 
 
You asked the Plan to waive this copayment. You say that this should be no charge because it was a follow up 
visit. The Plan denied your request. The Plan says this copayment was charged based on the claim submitted by 
the provider and the Plan contract agreement. 
 
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 $35 
copayment for specialist services. 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 $35 copayment charged for a specialist visit 
provided on July 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two additional intraoral x-rays provided on June 26, 2020. 
 
You asked the Plan to pay for two additional intraoral x-rays. You say that you were informed that dental x-
rays were fully covered. The Plan denied your request. The Plan says additional x-rays are not covered 
benefits. 
 
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 intraoral x-ray per calendar year. The Plan paid for one intraoral x-ray provided on June 26, 2020, which 
exhausted your benefit. Therefore, we decided that the Plan does not have to pay for two additional intraoral x-
rays provided on June 26, 2020.  
 
Your complaint about the dissatisfaction with the Plan representatives is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; single level (CPT Code 64493). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the service is not 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 service. Our physician reviewer 
found you have other multiple possible sources of your back pain. You have not had a recent surgical 
consultation. There is non-facet pathology that can explain the source of your pain, significant deformity (disc 
extrusion) and prior laminectomy. Therefore, the request is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or 
nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (CPT 
Code 64493).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $395 copayment charged for ambulance transport 
provided on June 7, 2020. 
 
You asked the Plan to waive this copayment. You say that you would like the Plan to waive this copayment. 
The Plan denied your request. The Plan says this copayment was charged based on the Plan contract agreement. 
 
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 $395 
copayment for ambulance transport.  
 
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 $395 copayment charged for ambulance transport provided on June 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on June 15, 2020 
and billed under code 99213. 
 
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 initial evaluation for minor surgical procedures and endoscopies is always included 
in the global surgery package. Visits by the same physician on the same day as a minor surgery or endoscopy 
are included in the global package, unless a significant, separately identifiable service is also performed. 
Modifier '-25' is used to bill a separately identifiable evaluation and management (E/M) service by the same 
physician on the same day of the procedure. The medical record documentation does not support a separate and 
significantly identifiable issue as the procedure was related to the chief complaint. Medicare billing criteria are 
not met.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the claim cannot be paid as billed as the 
medical records do not show a separate and distinct services. Medicare billing criteria are not met. Therefore, 
we decided that the Plan does not have to pay for physician services provided to the enrollee on June 15, 2020 
and billed under code 99213.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the $55.07 cost share charged for an electrocardiogram 
provided on November 5, 2019. 
 
You asked the Plan to waive this cost share. You say that you do not believe this copayment is correct. The 
Plan denied your request. The Plan says this copayment was less than the normal copayment expectation. 
 
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 $170 
copayment for outpatient diagnostic services. In this case you are being charged less than your normal 
copayment expectation for this service. 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 $55.07 cost share 
charged for an electrocardiogram provided on November 5, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the esophagogastroduodenoscopy (43247) provided on May 
5, 2020. 
 
You asked the Plan to pay for CPT code 43247. You say that the medical records support the billing of CPT 
code 43247 provided on May 5, 2020. The Plan denied your request. The Plan says the medical records do not 
support the billing of CPT code 43247 provided on May 5, 2020. 
 
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 43247 is esophagogastroduodenoscopy, flexible, 
transoral; with removal of foreign body(s). 
 
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 CPT code 43247. Our reviewer says that the 
medical records do not support the billing of CPT code 43247 provided on May 5, 2020. Our physician 
reviewer found the enrollee underwent esopahgogastroduodenoscopy with PEG tube placement on 5/5/20. The 
medical records do not contain documentation of upper gastrointestinal endoscopic removal of a foreign body. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CPT code 43247 have not been met. Therefore, we decided that the Plan does 
not have to pay for the esophagogastroduodenoscopy (43247) provided on May 5, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $40 copayment charged for specialist services provided on 
July 10, 2020. 
 
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The 
Plan denied your request. The Plan says this copayment was charged based on the services provided and the 
contract agreement. 
 
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 $40 
copayment for specialist services.  
 
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 $40 copayment charged for specialist services provided on July 10, 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 based on the documentation provided, the health plan's denial should be upheld. You 
do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen 
(15) hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) scan from the skull base to mid-thigh (78815). 
 
You asked the Plan to pre-approve a PET CT scan from the skull base to mid-thigh. You say that the services 
are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 a PET CT scan from the skull base to 
mid-thigh. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
documentation does not support that the PET/CT is being ordered to determine whether or not the enrollee is an 
appropriate candidate for an invasive diagnostic or therapeutic procedure, or to determine the optimal anatomic 
location for an invasive procedure, or to determine the anatomic extent of tumor when the recommended anti-
tumor treatment reasonably depends on the extent of the tumor. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a PET CT scan from the skull base to mid-thigh have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) scan from the skull base to mid-thigh (78815).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Memantine Hcl. 
 
You asked the Plan to pre-approve Memantine Hcl. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription 
coverage, therefore the criteria for self-administered drug coverage has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Memantine Hcl.  
 
Benefits for Memantine Hcl may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $35 copayment charged for physician services provided on 
July 2, 2020. 
 
You asked the Plan to waive this copayment. You say that this copayment is not correct. The Plan denied your 
request. The Plan says this copayment was charged based on the Plan contract agreement. 
 
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 $35 
copayment for specialist services. 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 $35 copayment charged for physician services 
provided on July 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve left side blepharoptosis repair (67904). 
 
You asked the Plan to pre-approve left side blepharoptosis repair. You say that you need this surgery. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that blepharoptosis repair is functional when 
overhanging skin or upper lid position secondary to dermatochalasis, blepharochalasis, blepharoptosis, or 
pseudoptosis is sufficiently low to produce a visually-significant field restriction considered by this policy to be 
approximately 30 degrees or less from fixation. 
 
We looked at the file and Medicare rules. The record shows that you have a prosthetic eye on the eye this 
surgery is requested for; therefore, the blepharoptosis does not affect your visual field and this surgery is not 
functional. Based on this information, we decided that Medicare rules for coverage of blepharoptosis repair 
have not been met. Therefore, we decided that the Plan does not have to pre-approve left side blepharoptosis 
repair (67904).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on March 16, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
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 the requested CPT codes are not supported in the medical record. Specifically, the records 
provided do not show that lab services were performed with blood sampling. The records show that a urine 
specimen was collected. The billed services cannot be verified. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on March 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an external ambulatory insulin delivery system (A9274) 
provided on April 20, 2020. 
 
You asked the Plan to pay for the external ambulatory insulin delivery system. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code A9274 
has a status indicator of I and 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 A9274 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code A9274 has a status indicator of I. This means that CPT code A9274 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the external ambulatory insulin 
delivery system have not been met. Therefore, we decided that the Plan does not have to pay for an external 
ambulatory insulin delivery system (A9274) provided on April 20, 2020.