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

 
We decided that the Plan has to pay for a magnetic resonance angiography (MRA) of the head (70544) 
provided on July 13, 2020. 
 
You asked the Plan to pay for a MRA of the head. You say that this procedure was performed. The Plan denied 
your request. The Plan says that this procedure requires a modifier due to NCCI edits. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. The rules also say that MACs subject all line items for the same beneficiary, same NPI, and same 
date of service to NCCI edits. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that this service denied due to NCCI edits; however, the paid 
code was rendered by a different provider. The case file and NPI numbers do not substantiate that this provider 
is in the same group practice. Therefore, we decided that the Plan has to pay for a magnetic resonance 
angiography (MRA) of the head (70544) provided on July 13, 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 pre-approve a dermatology referral for a biopsy of a bump on the 
face. 
 
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 cyst can be removed or left alone. 
 
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 referral is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the in-network doctor look at the bump and said it did not need a biopsy. The doctor said that it could be 
cosmetically removed. The clinical documentation in the case file does not support that a biopsy of a bump on 
your face is medically necessary and reasonable in this case. 
 
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 dermatology referral for a biopsy of a bump on the face.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 additional physical therapy visits. 
 
You asked the Plan to pre-approve the physical therapy visits. You say that the additional visits are medically 
necessary. The Plan denied your request. The Plan says 6 additional visits have been approved, 2 more are not 
medically necessary. 
 
 
The Plan follows Medicare rules. Medicare rules say that physical therapy is covered only when 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 physical therapy visits. Our 
reviewer says that the 2 additional visits are not medically necessary. Our physician reviewer found based on 
the records the patient appears to have reached a stage with therapy where the six approved additional visits to 
finalize a home exercise program are reasonable and necessary but further therapy beyond that does not appear 
to be likely to achieve any significant improvement in the patient's symptoms or functional status. 
 
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 physical therapy visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 2 additional physical therapy visits.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation rendered on May 1, 
2019. 
 
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 claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for these services was not filed until October 15, 2020. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the psychiatric diagnostic evaluation rendered on May 1, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 71045) provided on July 10, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a column II 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair, 
the column two code is denied, and the column one code is eligible for payment. Procedure code 71045 is part 
of an edit pair with procedure code 74022. Procedure code 74022 is a column one code, and procedure code 
71045 is a column two code. Procedure code 74022 has been on this date of service, which means that 
procedure code 71045 is not eligible for payment. Therefore, we decided that the Plan does not have to pay for 
the services (CPT 71045) provided on July 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (S9328) provided. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee 
Schedule indicates that the code in question is not valid for Medicare purposes.  
 
We looked at the file and Medicare rules. Code S9328 is assigned a status indicator of ?I? under the Physician 
Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for 
reporting of, and payment for, these services. 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 the 
services (S9328) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rehab therapies services provided on January 2, 2020, to 
January 27, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for rehab therapies service. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 rehab therapies services provided on January 2, 
2020, to January 27, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on February 22, 2019. 
 
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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing 
rendered on February 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the Magnetic Resonance Imaging provided 
on September 1, 2020. 
 
You asked the Plan to waive the copayment for the MRI. You say that you cannot afford this copayment The 
Plan denied your request. The Plan says you were charged this copayment 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 $150 
copayment for outpatient diagnostic tests.  
 
You have been asked to pay a $146.04 copayment, less than your required copayment, for the MRI. The MRI 
falls within the outpatient diagnostic tests 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 Magnetic Resonance Imaging provided on September 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pneumatic compression device (E0651) and sleeves (E0667) 
provided to the enrollee on May 4, 2020. 
 
You asked the Plan to pay for these services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says that the only time that a segmented, calibrated gradient pneumatic 
compression device would be covered is when the individual has unique characteristics that prevent them from 
receiving satisfactory pneumatic compression treatment using a non-segmented device. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when the above 
criteria have been met. 
 
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 these services. Our reviewer says that these 
services were not medically reasonable and necessary for the enrollee in this case. There is no clinical 
documentation of edema in the enrollee's lower extremities. There is no clinical documentation of one or more 
venous stasis ulcers. Our physician reviewer found that the enrollee's condition did not meet Medicare criteria 
for these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for pneumatic compression device (E0651) and sleeves (E0667) provided to the enrollee on May 4, 
2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the referral for revision of total knee arthroplasty with 
an out-of-network provider. 
 
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 requested surgery from a non-contracted facility is not approved. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers.  
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the referral for revision of total knee arthroplasty with an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided 
from June 8, 2020, to July 30, 2020. 
 
You asked the Plan to waive the copayments for outpatient rehabilitation services. You say that you were told 
that the Plan would cover whatever Medicare does not cover. The Plan denied your request. The Plan says the 
claims were processed correctly and you are being charged the correct amount. 
 
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 $35 
copayment for outpatient rehabilitation services.  
 
You received outpatient rehabilitation services provided from June 8, 2020, to July 30, 2020, for a total of 14 
visits. Therefore, you are responsible to pay a $35 copayment per each visit. The total amount you owe is: $35 
(copayment) x 14 (PT visits) = $490.  
 
You have been asked to pay the total copayment amount of $490 for outpatient rehabilitation services. 
Outpatient rehabilitation services fall within the outpatient rehabilitation 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 copayments for outpatient rehabilitation services provided from June 8, 2020, to 
July 30, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the colonoscopy rendered on July 8, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that the services were routine and 
should have no copayment. The Plan denied your request. The Plan says the copayment was 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 $200 
copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient 
facility.  
 
Review of the file shows that you had a diagnostic colonoscopy on July 8, 2020. You have been asked to pay a 
$200 copayment for these services. These services fall within the Medicare-covered outpatient surgery in an 
ambulatory surgical center or hospital outpatient facility 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 colonoscopy rendered on July 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abscess incision (46040) and debridement (11044 and 
11047) provided on March 30, 2020. 
 
You asked the Plan to pay for the abscess incision and debridement. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT codes 46040 
and 11044 were billed without an appropriate modifier and CPT code 11047 has not been billed with an 
appropriate primary procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT codes 46040, 11044 and 11047 are not supported in the record. Specifically, CPT codes 
46040 and 11044 have not been billed with the appropriate modifier to indicate that these services were 
unrelated to the surgical procedure. Additionally, CPT code 11047 is an add-on code and the record does not 
indicate that a primary procedure was billed and paid. Based on this information, we decided that Medicare 
rules for coverage of the abscess incision and debridement have not been met. Therefore, we decided that the 
Plan does not have to pay for the abscess incision (46040) and debridement (11044 and 11047) provided on 
March 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you the copayment for the operating room services 
provided on June 16, 2020 and July 16, 2020. 
 
You asked the Plan to reimburse you the copayment for the operating room services. You say that the shots did 
not work so you want a refund. The Plan denied your request. The Plan says you were charged the copayments 
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 $270 
copayment for Outpatient Surgery Services.  
 
You have been asked to pay a $270 copayment for each of the operating room services. The operating room 
services fall within the Outpatient Surgery 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 reimburse 
you the copayment for the operating room services provided on June 16, 2020 and July 16, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Botox and chemodenervation of the facial nerves for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no indication for Botox injections. 
 
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 the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found this request may be beneficial in patients with intractable, chronic migraine that has failed to respond to 
at least 3 conventional preventive medications. The injections are administered to the scalp and temple. They 
may reduce the frequency and severity of migraine attacks after 2-3 months of injections. The injections are 
expensive and must be administered every 2-3 months to maintain their effectiveness. The most appropriate 
duration of prophylactic therapy has not been determined. In most patients who are receiving prophylaxis, 
therapy must be continued for at least 3-6 months. The review has determined that the services at issue in this 
case are 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 services have been met. Therefore, we decided that the Plan has to pre-
approve Botox and chemodenervation of the facial nerves for the enrollee.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 27, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the portable x-ray.. You say that you would like reconsideration because this 
service was billed with the correct place of service. The Plan denied your request. The Plan says utilization of 
network providers is required when possible and available. 
 
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 July 27, 2020 by 
an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve the watchman device. 
 
You asked the Plan to pre-approve the watchman device. You say that you would like reconsideration because 
this service is necessary to prevent your ongoing bleeding problems. The Plan denied your request. The Plan 
says that the requirement of a formal shared decision making interaction with a non-interventional physician 
and information supporting your inability to take long-term oral anticoagulation is not documented. 
 
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 the watchman device. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found in this instance of intolerance or complications from anticoagulants, delay of the 
procedure could be detrimental to patient. The procedure is indicated. 
 
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 watchman device have been met. Therefore, we decided that the Plan has to 
pre-approve the watchman device.  
 
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.