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

 
We decided that the Plan does not have to waive the copayment for the transthoracic echocardiography (93306) 
provided on May 29, 2020. 
 
You asked the Plan to waive the copayment for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied 
correctly to the service 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 a $40 
copayment for each basic imaging service.  
 
You have been asked to pay a $40 copayment for the basic imaging service provided. 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 transthoracic echocardiography (93306) provided on May 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6240) for tooth #13 and retainer crowns 
(D6750) for tooth #'s 12 & 14. 
 
You asked the Plan to pre-approve the pontic and retainer crowns. The Plan denied your request. The Plan says 
these services are not medically necessary. 
 
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. The Plan covers the pontic and 
retainer crowns when the services are medically necessary and reasonable.  
 
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 pontic and retainer crowns. Our 
reviewer says that the services do not meet coverage criteria. Our physician reviewer found the request is for 
the placement of a fixed bridge from tooth #12 to #14, replacing toot #13.  These teeth are all in the posterior 
segment.  Our reviewer also found that, as the Plan does not allow for replacement of posterior teeth with a 
fixed appliance, the requested procedures are not found to be medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the pontic and retainer crowns have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a pontic (D6240) for tooth #13 and retainer crowns (D6750) for tooth #'s 
12 & 14.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia for diagnostic or therapeutic nerve blocks and 
injections (when block or injection is performed by a different physician or other qualified health care 
professional); prone position (CPT Code 01992) provided on April 20, 2020. 
 
You asked the Plan to pay for the service. You say that monitored anesthesia should be subject to the same 
level of payment as general or regional anesthesia. You state the services were performed by a contracted pain 
management provider. The Plan denied your request. The Plan says the service was 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 pay for the service. Our physician reviewer found 
the patient has no significant past medical history to warrant monitored anesthesia care (MAC). There is no 
documentation in the patient's record indicating that it is medically necessary to have an anesthesiologist 
present during a transforaminal epidural steroid injection (TFESI). Medical necessity for an anesthesiologist to 
administer MAC/intravenous (IV) sedation was not established. The review has determined that it is not 
medically necessary or reasonable for this enrollee to have IV sedation during the TFESI performed. 
 
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 pay for anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is 
performed by a different physician or other qualified health care professional); prone position (CPT Code 
01992) provided on April 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychiatric diagnostic evaluation (90791) rendered by the out 
of network (OON) provider on April 6, 2019. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for psychiatric diagnostic evaluation (90791) rendered by the out of network (OON) provider on 
April 6, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation provided on April 
18, 2020. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you needed the ambulance 
and are on a fixed income. The Plan denied your request. The Plan says the copayment amount you are being 
charged is correct. 
 
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 $260 
copayment for each one-way ambulance trip by ground.  
 
You have been asked to pay $260 copayment for ambulance transport. Ambulance transport falls within the 
Ambulance Services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance 
transportation provided on April 18, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the chest x-ray (71045) provided on April 20, 2020. 
 
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says that an appropriate modifier is needed to represent that 
71045 is separate and distinct from column I codes 77001 and 36558. 
 
The Plan must follow Medicare rules. Medicare rules say that MACs subject all line items for the same 
beneficiary, same NPI, and same date of service to NCCI edits.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the chest x-ray have been met. The record indicates that CPT code 71045 was rendered by a 
provider with a different NPI than those who rendered column I codes 77001 and 36558. The NCCI edits are 
inappropriate in this case. Therefore, we decided that the Plan has to pay for the chest x-ray (71045) provided 
on April 20, 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 a telephone visit provided on May 13, 2020. 
 
You asked the Plan to pay for the telephone visit. The Plan denied your request. The Plan says you must 
receive your care from a network provider. In most cases, care you receive from an out-of-network provider 
will not be covered. 
 
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 
service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we 
decided that the Plan does not have to pay for a telephone visit provided on May 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on January 22, 2020. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require 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 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 domiciliary, rest home visit provided on January 22, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit (99285) provided on 
December 18, 2019. 
 
You asked the Plan to pay for the emergency department visit. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the submitted documentation 
supports one unit of 99285 which has already been processed and paid. 
 
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 99285 is not supported in the record. Specifically, the record indicates that one unit of 
99285 has been processed and paid. This evaluation and management service was processed for a provider in 
the same group with the same specialty. Only one evaluation and management service may be reported per day 
by physicians in the same group with the same specialty. Based on this information, we decided that Medicare 
rules for coverage of the emergency department visit have not been met. Therefore, we decided that the Plan 
does not have to pay for the emergency department visit (99285) provided on December 18, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the chemotherapy services rendered on March 23, 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 codes 96413 and 96415 are 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 96413 is chemotherapy administration, intravenous 
infusion technique; up to 1 hour, single or initial substance/drug. The definition of code 96415 is chemotherapy 
administration, intravenous infusion technique; each additional hour (List separately in addition to code for 
primary procedure). 
 
We find that CPT codes 96413 and 96415 are not supported in the medical record. Specifically, there is no 
documentation of chemotherapy administration using intravenous infusion for up 1 to one hour for the billed 
date of service to support code 96413. There is no documentation of any additional hours to support code 
96415. 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 chemotherapy services rendered on 
March 23, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for lumbar-sacral orthosis (L0650) and a wrist splint (L3916) provided on 
March 2, 2020 
 
You asked the Plan to pay for the lumbar-sacral orthosis and wrist splint. You say that you would like 
reconsideration because these supplies are medically necessary. The Plan denied your request. The Plan says 
that the delivery ticket does not include a tracking number or itemized shipping/billing invoice. 
 
The Plan must follow Medicare rules. Medicare rules say that the supplier for all Durable Medical Equipment, 
Prosthetic, and Orthotic Supplies (DMEPOS) must have an order from the treating physician before giving any 
DMEPOS item to an enrollee. The supplier must keep the order and proof of delivery documentation on file. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lumbar-sacral orthosis and wrist splint have been met. Specifically, the record includes a 
physician order and valid proof of delivery. Therefore, we decided that the Plan has to pay for lumbar-sacral 
orthosis (L0650) and a wrist splint (L3916) provided on March 2, 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 anesthesia for diagnostic or therapeutic nerve blocks and 
injections (when block or injection is performed by a different physician or other qualified health care 
professional); prone position (CPT Code 01992) provided on April 21, 2020. 
 
You asked the Plan to pay for the service. You say that monitored anesthesia should be subject to the same 
level of payment as general or regional anesthesia. You state the services were performed by a contracted pain 
management provider. The Plan denied your request. The Plan says the service was 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 pay for the service. Our physician reviewer found 
the patient has no significant past medical history to warrant monitored anesthesia care (MAC). There is no 
documentation in the patient's record indicating that it is medically necessary to have an anesthesiologist 
present during a lumbar epidural steroid injection (LESI). Medical necessity for an anesthesiologist to 
administer MAC/intravenous (IV) sedation was not established. The review has determined that it is not 
medically necessary or reasonable for this enrollee to have IV sedation during the LESI performed. 
 
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 pay for anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is 
performed by a different physician or other qualified health care professional); prone position (CPT Code 
01992) provided on April 21, 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 for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and 
does not require transfer to LTACH. 
 
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 reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The patient 
is currently undergoing treatment at an acute care hospital (ACH) following surgery for ischemic colitis. The 
enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not 
currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no 
advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such 
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for 
any ongoing long term care needs. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a long history of 
follicular lymphoma with a history of three prior PET scans. Given that she has had three prior scans, a 
subsequent PET is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro 2 Motion G Orthotic device for the enrollee. 
 
You asked the Plan to pre-approve a MyoPro 2 Motion G Orthotic device. You say that this item is medically 
necessary. The Plan denied your request. The Plan says that your request is not medically necessary because 
this device has deluxe features that exceed the enrollee's need and replaces, rather than improves the function 
of the enrollee's 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 a MyoPro 2 Motion G Orthotic device. 
Our reviewer says that a MyoPro 2 Motion G Orthotic device is not considered medically reasonable and 
necessary in this case. There is insufficient literature in the peer reviewed publications to assess safety, 
efficacy, long term outcomes or patient management associated with the use of the MyoPro Orthosis for upper 
extremity paralysis/paresis from conditions such as the patient's brachial plexus injury, or other 
neuromuscular/neurological disease or injury. Our physician reviewer found that the enrollee's condition does 
not meet criteria for coverage of this item. 
 
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 MyoPro 2 Motion G Orthotic device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a MyoPro 2 Motion G Orthotic device for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional seven skilled nursing home health visits 
for the enrollee. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary The Plan 
denied your request. The Plan says the records do not support the need for a skilled nurse to make more visits. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional visits. Our reviewer says 
that the requested visits are not medically reasonable or necessary. Our physician reviewer found the records do 
not show that skilled nursing services are required to effectively provide treatment, care, and/or services in 
order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the 
enrollee's condition and/or prevent deterioration. The enrollee has had prior SN for disease and medication 
management and education. The enrollee's conditions are chronic and there is no evidence of complex wound 
care or other SN need. 
 
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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an additional seven skilled nursing home health visits for the enrollee.