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

We decided that the Plan does not have to pay for the ultrasound coded 76642 and the diagnostic 
mammography services coded 77066 provided on August 6, 2020. 
 
You asked the Plan to pay for the ultrasound and the diagnostic mammography 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 not payable. 
 
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 codes 76642 and 77066 are not supported in the medical record. Specifically, the 
documentation supports that one unit of each 76642-LT, 76642-RT, and 77066 were provided, which were 
previously approved and paid. There is no additional documentation supporting additional studies which were 
billed. Based on this information, we decided that Medicare rules for coverage of the ultrasound and the 
diagnostic mammography services have not been met. Therefore, we decided that the Plan does not have to pay 
for the ultrasound coded 76642 and the diagnostic mammography services coded 77066 provided on August 6, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a bilateral face steroid injection. 
 
You asked the Plan 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 (64493). You say that the plan is to treat the enrollee's pain non-surgically. The Plan denied 
your request. The Plan says that the recent lumbar decompression with discectomy provided only short lived 
relief. 
 
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 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 (64493). Our reviewer says that the requested services are 
considered medically reasonable and necessary in this case. Our physician reviewer found the request meets the 
LCD criteria and is 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 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 (64493) have been met. Therefore, we decided that the Plan has to pre-approve a bilateral 
face steroid injection.  
 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair van transportation services to and from 
infusion appointments. 
 
You asked the Plan to pre-approve the transportation services. You say that you do not have transportation to 
take yourself to these appointments. The Plan denied your request. The Plan says these services are not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pre-approve are wheelchair van transport services. Therefore, we 
decided that the Plan does not have to pre-approve wheelchair van transportation services to and from infusion 
appointments.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services provided on July 12, 2020. 
 
You asked the Plan to pay for the emergency room services. You say that the medical records provided support 
the services in dispute. The Plan denied your request. The Plan says the provider who supplied the emergency 
room services in dispute is a non-Medicare approved freestanding emergency facility. 
 
The Plan must follow Medicare rules. Medicare rules say that services in an emergency department is only 
covered if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The records show that the provider in this case is a freestanding 
emergency room that is not affiliated with a hospital. Based on this information, we decided that Medicare 
rules for coverage of the emergency room services have not been met. Therefore, we decided that the Plan does 
not have to pay for emergency room services provided on July 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromonitoring services (95999) provided December 3, 
2019. 
 
You asked the Plan to pay for the neuromonitoring services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the CPT code billed is not payable. 
 
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 95999 is not supported in the medical record. Specifically, per Medicare rules, the 
nerve testing is integral to the procedure and is not separately reportable. Based on this information, we decided 
that Medicare rules for coverage of the neuromonitoring services have not been met. Therefore, we decided 
that the Plan does not have to pay for neuromonitoring services (95999) provided December 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of a MyoPro Motion G orthotic device. 
 
You asked the Plan to pre-approve MyoPro Motion G. You say that robotic rehabilitation is a standard of care 
that is better proven than many other universally accepted options. The Plan denied your request. The Plan says 
the denial of authorization for this device is correct, because this device has deluxe features that exceed the 
enrollee's need and it replaces, rather than improves, the function of the arm. 
 
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 MyoPro Motion G. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the literature is insufficient in terms of effectiveness and safety of this device for the 
enrollee's condition of hemiparesis post-stroke. At this time the requested orthosis is not proven to be more 
beneficial for treatment of the enrollee's hemiparesis from stroke than any available standard therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MyoPro Motion G have not been met. Therefore, we decided that the Plan does 
not have to pre-approve use of a MyoPro Motion G orthotic device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for OON services. You say that the enrollee was evaluated for post-operative 
treatment. The Plan denied your request. The Plan says the services were not urgent, emergent, or 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 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 OON services. Therefore, we decided that the 
Plan does not have to pay for the medical services provided, by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 17, 2019 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 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 the medical services provided on December 17, 
2019 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 upper partial denture (D5213) and the lower partial 
denture (D5214) provided. 
 
You asked the Plan to pay for the dental items. You say that a plan representative assured your wife that 50% 
of this procedure would be covered by insurance. You say that you decided to move forward with the 
procedure based on this information. You say that once you received the Evidence of Benefits (EOB), you 
called again and were advised that none of the procedure was covered. You also say that you would like the 
services to be covered at 50% like you were quoted initially. The Plan denied your request. The Plan says there 
is an annual maximum benefit of $1,000. The Plan also says that the annual maximum benefit has been 
exceeded. 
 
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 and dentures are listed as covered at 
50%, the annual maximum benefit of $1,000 that the Plan will pay for covered services has been exceeded. 
Therefore, we decided that the Plan does not have to pay for the upper partial denture (D5213) and the lower 
partial denture (D5214) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the romosozumab injection provided on 
September 14, 2020. 
 
You asked the Plan to waive the coinsurance for the romosozumab injection. You say that you weren't made 
aware that the injection would be so expensive. The Plan denied your request. The Plan says the coinsurance 
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 20% 
coinsurance for each Medicare-covered Part B drug from an in-network provider. 
 
You have been asked to pay $380.10, which is 20% of the allowed amount for the romosozumab injection. The 
allowed amount is $1,900.50 (20% x $1,900.50 = $380.10). The romosozumab injection falls within the 
"Medicare Part B prescription drugs" 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 coinsurance for 
the romosozumab injection provided on September 14, 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 July 27, 
2020, through August 2, 2020. 
 
You asked the Plan to waive the copayment for the inpatient stay. You say that you are on a fixed income and 
don't have the money to pay. 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 $225 
copayment per day (per Medicare-covered stay) which includes day of admission and day of discharge, for 
days 1-7 for each inpatient stay. 
 
You have been asked to pay a $1,350 copayment for the inpatient stay. ($225/day x 6 days = $1,350). 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 July 27, 2020, through August 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral-periapical additional radiographic image 
(D0230), an unspecified preventive procedure (D1999), and 3 dental fillings (D2331, D2392, D2393) received 
on July 9, 2020. 
 
You asked the Plan to pay for an intraoral-periapical additional radiographic image, an unspecified preventive 
procedure, and 3 dental fillings. You say that the Plan should review this claim again. The Plan denied your 
request. The Plan says rules for payment have not been met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers an intraoral-
periapical radiographic image once per calendar year and dental fillings twice per calendar year.  
 
We looked at the case file and Medicare rules. The case record documents that the Plan has paid for intraoral-
periapical radiographic image and 2 fillings received on July 9, 2020. Based on this information, we decided 
that the Plan's rules for coverage of an intraoral-periapical additional radiographic image and 3 dental fillings 
have not been met. Additionally, though the Plan offers a dental benefit in excess of Medicare coverage, an 
unspecified preventive procedure is not among the procedures covered under this benefit. Therefore, we 
decided that the Plan does not have to pay for an intraoral-periapical additional radiographic image (D0230), an 
unspecified preventive procedure (D1999), and 3 dental fillings (D2331, D2392, D2393) received on July 9, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for personal protective equipment (PPE) charge on July 27, 
2020. 
 
You asked the Plan to pay for PPE charge. You say that you should be reimbursed for this charge. The Plan 
denied your request. The Plan says the service is not a covered benefit. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for personal 
protective equipment (PPE) charge on July 27, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 hours of additional home health aide services. 
 
You asked the Plan to pre-approve additional home health aide. You say that you need additional home health 
aide hours. The Plan denied your request. The Plan says your need for home health aide is met with the 
approved 2 hours per week. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 additional home health aide. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the documentation 
does not support that you require any further home health hours in addition to the already approved 2 hours 
weekly. You have been medically stable without any recent exacerbations of chronic medical problems or 
hospitalizations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional home health aide have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 12 hours of additional home health aide services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Zoster (shingles) vaccine (90750) vaccine administration 
(90471) provided August 6, 2020. 
 
You asked the Plan to pay for the injection services. You say that you were told by the doctor's nurse that there 
was no charge for the shingles shot. Now you've received a bill for $203 which was a total surprise. The Plan 
denied your request. The Plan says this service is not covered under the plan benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pay for Zoster (shingles) vaccine (90750) vaccine administration (90471) provided 
August 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 3, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
 
 
 
 
 
 
 
 
 
 
 
The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on February 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has a better chance of 
staying off the trach in the LTACH. The Plan denied your request. The Plan says the enrollee's medical needs 
are being met in the current acute setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our physician 
reviewer found that the enrollee presented to the acute hospital with shortness of breath, fever, hypoxia and 
lactic acidosis in the setting of known Covid-19 status. The enrollee still requires acute hospital level of care 
services, and is receiving appropriate care at the present acute care hospital. The enrollee does not require 
services at the LTACH that are not available at the acute care hospital where he is currently receiving care. 
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the health plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the vitamin b12 injection provided on August 26, 
2020 and September 24, 2020. 
 
You asked the Plan to waive the coinsurance for the vitamin b12 injections. You say that you have been getting b12 shots 
for the past 10 years and never received a copayment. You say that it is ridiculous to send a bill for such a tiny amount. 
The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance 
for Medicare Part B non-chemotherapy prescription drugs. 
 
You have been asked to pay $0.68, which is 20% of the allowed amount for the vitamin b12 injection.  
 
Date of Service Service Allowed Amount Coinsurance Member Liability 
August 26, 2020 B12 Injection $1.72 20% $0.34 
September 24, 2020 B12 Injection $1.72 20% $0.34 
TOTAL:    $0.68 
 
The vitamin b12 injection falls within the "Medicare Part B prescription drugs" 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 coinsurance for the vitamin b12 injection provided on August 26, 2020 and September 24, 2020.