Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tertiary level referral to a cardiologist for the enrollee. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the notes do not show that a redirection would cause a delay in care. 
 
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 referral. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee is clinically stable, and needs a letter addressed to the DMV in an effort to get his driver's 
license restored. In this circumstance, the records do not support the medical necessity for a tertiary level of 
care cardiologist. Redirection would not cause a delay in 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 the referral have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a tertiary level referral to a cardiologist for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral lower limb prostheses and additions. 
 
You asked the Plan to pre-approve the lower extremity prostheses, foot, flexible keels (L5972). You say that 
you need the bilateral lower limb prostheses and additions. The Plan denied your request. The Plan says the 
requested prosthetic feet exceed your need. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The record shows you are a functional Level 1. Based on this 
information, we decided that Medicare rules for coverage of the lower extremity prostheses, foot, flexible keels 
(L5972) have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral lower 
limb prostheses and additions.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hip surgery rendered on April 15, 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 27250 was not billed correctly. 
 
The plan must follow Medicare rules. The rules say that anatomical modifiers are required for procedures 
performed on different anatomical sites. 
 
We looked at the file and Medicare rules. The file shows that procedure code 27250 (closed treatment of hip 
location) was not billed with a required anatomical modifier. 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 hip surgery rendered on April 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient stay provided from February 
15, 2020, through February 19, 2020. 
 
You asked the Plan to waive the copayment for the inpatient stay. You say that you had delayed response from 
staff and your release was delayed due to being moved to a different room. You say that you should be released 
from member responsibility. The Plan denied your request. The Plan says the copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment per day, days 1 to 5, at an in-network inpatient hospital. 
 
You have been asked to pay a $300 copayment for the inpatient stay. ($100/day x 3 days = $300). The inpatient 
stay falls within the "Inpatient hospital care" benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for the inpatient stay provided from February 15, 2020, through February 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiography (93016, 93018) services provided July 8, 2020. 
 
You asked the Plan to pay for the cardiography services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim included an inappropriate modifier and cannot be paid as 
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. 
 
We find that CPT code 93016 and 93018 is not supported in the medical record. Specifically, the ME modifier 
used is reserved for advanced diagnostic imaging procedures. The CPT codes billed are cardiography 
procedures and are not considered advanced diagnostic imaging procedures. Based on this information, we 
decided that Medicare rules for coverage of the cardiography services have not been met. Therefore, we 
decided that the Plan does not have to pay for cardiography (93016, 93018) services provided July 8, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for needle electromyography services (CPT 51785) provided to 
the enrollee on July 10, 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 experimental or investigational services are not covered. 
 
 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no diagnosis of stress or urge incontinence, mechanical or functional incontinence, or other 
forms of incontinence prior to surgery.  Nor did she have any history of such problems. Inasmuch it cannot be 
said that the enrollee met criteria for coverage of this service. 
 
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 needle electromyography services (CPT 51785) provided to the enrollee on July 10, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ambulance services provided to the enrollee on June 1, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that there was no other option for the enrollee's 
transfer due to his immobility and the pain he was suffering. The Plan denied your request. The Plan says that 
that the records indicate that the enrollee could have been transferred by wheelchair. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same rules.  
 
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 ambulance services. Our reviewer says 
that the ambulance services were medically reasonable and necessary for the enrollee. The enrollee is an 
elderly patient with chronic pain and no use of legs. There was not sufficient evidence that other means of 
transport were feasible without causing undue discomfort to patient. Our physician reviewer found that the 
enrollee's condition meets Medicare criteria for ambulance services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ambulance services have been met. Therefore, we decided that the Plan has 
to pay for the ambulance services provided to the enrollee on June 1, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on July 22, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider 
on July 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist services rendered on July 1, 
2019 and October 2, 2019. 
 
You asked the Plan to waive the copayments for these services. You say that you disagree with the charges. 
The Plan denied your request. The Plan says the copayments were applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for services obtained from a specialist. 
 
Review of the file shows that you received specialist services on July 1, 2019 and October 2, 2019. Per the 
contract with the Plan, there is a $25 copayment for services obtained from a specialist. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed 
amount for these services was $24.25. Given that the allowed amount was less than the $25 copayment, you 
have been asked to pay $24.25 per date of service, for a total of $48.50, for these services. 
 
Therefore, we decided that the Plan does not have to waive the copayments for the specialist services rendered 
on July 1, 2019 and October 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a BiPAP machine battery pack (E1399). 
 
You asked the Plan to pre-approve this item. You say that at this time a BiPAP machine is the only device the 
member has at home to support his failing respiratory system. It is necessary to have a battery for this device in 
the event of a power failure. The Plan denied your request. The Plan says a battery for the BiPAP machine is 
not a covered benefit under the member's contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature, as it does not 
directly treat the member?s medical condition. In addition, this item serves the same purpose as the power 
connector included with the BiPAP device. Therefore, we decided that the Plan does not have to pre-approve a 
BiPAP machine battery pack (E1399).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (CPT 74248) provided to the enrollee on 
July 17, 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 add-on codes are always performed in addition to the primary service or procedure and must 
never be reported as a stand-alone code. 
 
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 74248 is Radiologic examination, upper gastrointestinal 
tract, including scout abdominal radiograph(s) and delayed image(s), when performed with small intestine 
follow-through study, including multiple serial images.
 
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 
services at issue in this case were not supported by the medical records. Our coding reviewer found the 
documentation submitted was reviewed and does not meet criteria. CPT 2020 updates deleted (74241, 74245, 
74247, 74249) and adds small intestine follow-through code +74248 for use with 74240 and 74246. +74248 is 
an "add-on" code and requires the appropriate primary code. 
 
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 radiology services (CPT 74248) provided to the enrollee on July 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided February 17, 2020 
to February 18, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says inpatient care was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the patient's necessary hospital care (including earlier Emergency and/or 
observation care) would span two midnights. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided February 17, 2020 to February 18, 
2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transport provided to the enrollee on June 13, 
2020. 
 
You asked the Plan to pay for this claim. You say that this transport should be covered by the Plan. The Plan 
denied your request. The Plan says it was verified with the Coordination of Benefits Team on September 18, 
2020 that the enrollee had another primary insurer from May 01, 2019 to October 31, 2019. At that time the 
Plan was secondary to this primary. The Plan confirmed this primary insurer covered the enrollee for the date 
of service in question. The Plan says that based on the Medicare regulations, the plan is upholding its decision 
to deny payment as it is the provider?s responsibility to bill the primary and any liability insurance before 
submitting the claim to the enrollees secondary Plan.  
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. The Plan has met its obligation with 
regards to coordination of benefits. Specifically, the Plan has identified the primary and given instruction on 
submitting the claim. As the secondary insurer, the Plan cannot be held responsible for this claim until the 
primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to 
pay for ambulance transport provided to the enrollee on June 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Lite test strips. 
 
You asked the Plan to pre-approve Freestyle Lite test strips. You say that the requested Freestyle Lite test strips 
are medically necessary The Plan denied your request. The Plan says the requested Freestyle Lite test strips are 
not medically necessary as the enrollee is currently approved for a continuous glucose monitor. 
 
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 Freestyle Lite test strips. Our reviewer 
says that the requested Freestyle Lite test strips are not medically necessary. Our physician reviewer found 
based on the documentation provided, the enrollee is noted to be a type I diabetic, who uses an insulin pump 
and a CGM. The enrollee is also noted to test her blood glucose 8-10 times a day with a BGM. A request has 
been made for test strips to be used with the BGM. It is unclear why the enrollee is using both a CGM and a 
BGM. The use of a CGM should do away with the need to use a BGM. There is no evidence that the CGM is 
broken or malfunctioning. The requested BGM test strips are not shown to be medically necessary or 
reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Freestyle Lite test strips have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Freestyle Lite test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider on September 13, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 services at issue in this appeal. 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 the medical services provided to you by an out-of-network provider on 
September 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of ankle (73720). 
 
You asked the Plan to pre-approve the MRI. 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 requested 
service as medically necessary. 
 
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 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this enrollee has several years of history of left ankle/foot pain. There are no current medical 
records submitted for review. The referral system information indicates she has worsening neurogenic pain, 
swelling, and limited range of motion. She has been diagnosed with tarsal tunnel syndrome. This is noted to be 
for pre-surgical planning. Current evidence based medical literature does not support MRI as sensitive for the 
diagnosis of tarsal tunnel, and other indications for this study have not been documented. There is insufficient 
medical documentation to support the medical necessity of this request at this time. There is no evidence of 
current subjective complaints, functional limitations, objective findings, x-ray findings, or surgical treatment 
plan. Therefore, this request for MRI of the ankle is not medically reasonable and 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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of ankle (73720).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete upper and lower dentures. 
 
You asked the Plan to pre-approve the complete upper and lower dentures. You say that you are having 
difficulty eating and are struggling with indigestion due to the broken dentures. The Plan denied your request. 
The Plan says your benefit for dentures is currently exhausted. 
 
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 coverage for dentures is limited to 
one set every 60 months. The records show that you received coverage for dentures provided on April 16, 
2016. This is less than 60 months ago. Therefore, we decided that the Plan does not have to pre-approve 
complete upper and lower dentures.