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

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain 
rendered on September 18, 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 procedure code 70450 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 70450 and 70496. Code 70450 is a column II code with a 
modifier indicator of 1 when billed with column I code 70496. Code 70450 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the 
computed tomography (CT) scan of the head/brain rendered on September 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a Superion interspinous spacer. 
 
You asked the Plan to pre-approve the Superion procedure. You say that this is needed as her pain is so severe 
she is barely able to walk. In addition, she meets the FDA indications for this procedure. The Plan denied your 
request. The Plan says this procedure is not proven and is still considered experimental. 
 
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 Superion procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the spacer is experimental. More research is needed to show safety and efficacy. 
 
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 Superion procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of a Superion interspinous spacer.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxycodone-Acetaminophen for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
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 Oxycodone-Acetaminophen 
for the enrollee.  
 
Benefits for this drug 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 pay for the hospital discharge services rendered on January 6, 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 procedure code 99239 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 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, there is no documentation of 
more than 30 minutes of discharge services spent on the enrollee. 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 hospital discharge services rendered on January 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), prophylaxis 
(D1110), the bitewing x-rays (D0274), and the panoramic x-ray (D0330) provided on September 29, 2020. 
 
You asked the Plan to pay for the dental services. You say that you moved here recently. You say that you did 
not see in any of the provided information did it mention "opted out of Medicare". The Plan denied your 
request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment 
cannot be made for services that you receive from a provider that has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation (D0150), prophylaxis (D1110), the bitewing x-rays (D0274), and the panoramic 
x-ray (D0330) provided on September 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tendon sheath incision (36055) provided on July 8, 2020. 
 
You asked the Plan to pay for the tendon sheath incision. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the documentation submitted does not 
support 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 26055 is tendon sheath incision (eg, for trigger finger). 
 
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 tendon sheath incision. Our reviewer says that CPT code 
26055 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical 
records provided do not include documentation to support a Tendon sheath incision ( (eg, for trigger finger) on 
the right hand, fourth digit being performed on July 8, 2020, 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 tendon sheath incision have not been met. Therefore, we decided that the 
Plan does not have to pay for the tendon sheath incision (36055) provided on July 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation with medical services 
provided on 
October 22, 2019. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation with medical services. 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 psychiatric diagnostic evaluation with medical services 
provided on October 22, 2019.
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, falls and abdominal pain. Medical conditions are stable. There are no medical needs 
requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee 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 enrollee 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Qutenza 8% patch kit. 
 
You asked the Plan to pre-approve the Qutenza patch. You say that this treatment is medically necessary. The 
Plan denied your request. The Plan says the self-applied patch is dispensed by a pharmacy and must be paid by 
Part D. 
 
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 the Qutenza 8% patch kit.  
 
Benefits for the Qutenza patch 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: Favorable

 
We decided that the Plan has to pay for the inpatient physician services provided 

You asked the Plan to pay for the inpatient physician services. You say that this claim should be paid based on 
the submitted W-9 form. The Plan denied your request. The Plan says that this claim was approved for 
payment; however, the claim then denied due to coordination of benefit. The services must be billed to the 
primary payer prior to the Plan making payment. 
 
The Plan must follow Medicare rules. Medicare rules say that health plans must identify payers which are 
primary to Medicare and coordinate benefits to the enrollee with the benefits of the primary payer. Plans can 
coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the 
primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. 
Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. 
 
In this case, although the plan states that there is a payer that is primary to Medicare, the Plan does not identify 
this payer. As such, they have not been able to direct the provider to send the bill to this primary payer. In this 
circumstance, the Plan must make payment for these services and seek reimbursement from the primary payer.  
Therefore, we decided that the Plan has to pay for the inpatient physician services provided
 
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 laboratory services (CPT 81521) provided to the enrollee on 
June 11, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 81521 (1 Unit) remains 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 81521 is "Oncology (breast), mRNA, microarray gene 
expression profiling of 70 content genes and 465 housekeeping genes, utilizing fresh frozen or formalin-fixed 
paraffin-embedded tissue, algorithm reported as index related to risk of distant metastasis." 
 
We find that CPT code 81521 is not supported in the medical record. Specifically, the place of service on the 
CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a 
place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's 
office (POS 11). 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 laboratory services (CPT 81521) 
provided to the enrollee on June 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 Sensor. 
 
You asked the Plan to pre-approve a Dexcom G6 Sensor. 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 the information submitted by the supplier or 
provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare 
coverage criteria have been met.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Dexcom G6 Sensor have not been met. Specifically, medical records were not provided. Without 
this documentation, medical necessity is not able to be established. Therefore, we decided that the Plan does 
not have to pre-approve a Dexcom G6 Sensor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gene expression analysis testing (CPT 81545) provided to the 
enrollee on September 19, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says there was a lack of prior authorization. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found no provider records were submitted for review.  Therefore, there is no evidence to show that the enrollee 
met any of the clinical criteria required for test coverage (nodule growth, Fm Hx, Sxs, radiation exposure, 
LAN). The documentation does not support that the performed testing was medically necessary, reasonable or 
coverable. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for gene expression analysis testing (CPT 81545) provided to the enrollee on September 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous spacer device. 
 
You asked the Plan to pre-approve the requested device. You say that without the requested service, the pain 
will worsen. The Plan denied your request. The Plan says the service is not identified as generally accepted for 
the proposed use. 
 
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 requested device. Our physician 
reviewer found that you have chronic low back pain with neurogenic claudication. You had an L5 vertebral 
body fracture with a kyphoplasty performed recently. The requested interspinous spacer is considered an 
experimental/investigational procedure. Therefore, the request is considered 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 requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an interspinous spacer device.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to hold you harmless for IRF care received on July 1 to July 17, 2020. 
 
You asked the Plan to hold you harmless for IRF care. You say that you are uncertain why the services in 
question have been denied. The Plan denied your request. The Plan says that rules for payment have not been 
met because prior authorization was not obtained. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for IRF care by a contract provider. The file does not show that the Plan provided notice that 
IRF care would not be covered. Under Medicare rules, this means IRF care is considered approved by the Plan. 
Therefore, we decided that the Plan has to hold you harmless for IRF care received on July 1 to July 17, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 5, 2020, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 the medical services provided on August 5, 2020, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the filling (D2392) for tooth # 29 and the pulp cap, indirect, 
(D3120) provided on September 3, 2020. 
 
You asked the Plan to pay for the dental services. You say that the provider wants you to pay for their mistake. 
You also say that you only wanted the filling that would be covered. The Plan denied your request. The Plan 
says 1 filling per calendar year is covered. The Plan says that the frequency limit for fillings has been exceeded. 
The Plan also says that pulp cap is not listed as a covered service. 
 
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, the frequency limit of 1 filling per 
calendar year has been exceeded. The record shows that the Plan paid for the filling for tooth # 6. Additionally, 
the pulp cap is not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pay for the filling (D2392) for tooth # 29 and the pulp cap, indirect, (D3120) provided on September 3, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Automatic External Defibrillator provided on August 12, 
2020 by an out of network provider. 
 
You asked the Plan to pay for the Automatic External Defibrillator. You say that you don?t know why your 
doctor did not get authorization.  The Plan denied your request. The Plan says the Automatic External 
Defibrillator was not prescribed or authorized by your Primary Care Physician for this date of service. 
 
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 at issue in this appeal. The initial date of service June 10, 2020 
was covered. The Plan did not pre-approve the item at issue for this date of service. We found no exception that 
would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for the 
Automatic External Defibrillator provided on August 12, 2020 by an out of network provider.