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

 
We decided that the Plan does not have to waive the $40 copayment charged for physician services provided on 
August 4, 2020. 
 
You asked the Plan to waive this copayment. You say that this copayment is not correct. The Plan denied your 
request. The Plan says this copayment is a contractual obligation. 
 
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 $40 
copayment for specialist services.  
 
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 $40 copayment charged for physician services provided on August 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a laparascopy procedure (CPT 50949 and CPT 58660) 
provided to the enrollee on April 15, 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 the denied codes remain 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 the denied codes is: 
 
CPT 50949: 
 
unlisted laparoscopy procedure of the ureter 

CPT 58660: 
 
laparascopy, surgical; with lysis of adhesions (salpingolysis, ovariolysis) (separate procedure) 

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 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
enrollee was known to have renal cancer and was scheduled to undergo a nephrectomy to remove the kidney 
and its tumor. During the nephrectomy, it was determined that the cancer was already too locally invasive to 
allow for safe and complete removal.  As such, the nephrectomy was aborted.  The completed lysis of 
adhesions and distal ureter lysis were steps taken in preparation for the nephrectomy, and are considered 
secondary to and part of the nephrectomy. The bill should indicate that a nephrectomy was performed, but 
should use a modifier to indicate that the procedure was aborted. The bill can also indicate that additional intra-
abdominal lysis of adhesions was required. The bill should not indicate that the primary procedure was a distal ureter lysis (CPT 50949) or that adnexal lysis of adhesions was performed (CPT 58660). 
 
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 a laparascopy procedure (CPT 50949 and CPT 58660) provided to the enrollee on April 15, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on May 7, 2020 and 
billed under codes 80157, 80177, 80201, 80162, 80159 and 80173. 
 
You asked the Plan to pay for lab services provided to the enrollee. You say that this claim should be paid. The 
Plan denied your request. The Plan says the documentation submitted did not support that the denied testing 
was performed with blood sampling.  Blood specimen collection is by venipuncture; however, the lab 
requisition states a urine specimen was collected; therefore, the billed service cannot be verified. It is noted 
multiple attempts were made to obtain additional information from the provider. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case the claim submitted cannot be paid due 
to an issue with the type of specimen reported. Medicare billing criteria were not met. Therefore, we decided 
that the Plan does not have to pay for lab services provided to the enrollee on May 7, 2020 and billed under 
codes 80157, 80177, 80201, 80162, 80159 and 80173.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sleep study (95806). 
 
You asked the Plan to pre-approve the sleep study. You say that you would like reconsideration because the 
sleep study is medically necessary. The Plan denied your request. The Plan says the member has no 
documentation of signs or symptoms of OSA. 
 
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 sleep study. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there was no discussion of the member's sleep or symptoms which would readily suggest the 
presence of OSA. In this setting the documentary requirements of the LCD cannot be considered to have been 
satisfied. Furthermore, it is otherwise unclear why repeat sleep testing was ordered for this member. 
 
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 sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the sleep study (95806).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 25, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the creation of arteriovenous fistula by other than direct arteriovenous 
anastomosis (36830). You say that you would like reconsideration to be processed at the member's in-network 
benefit level. The Plan denied your request. The Plan says the member does not have out-of-network benefits. 
 
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 June 25, 2020 by 
an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services (CPT 90832) provided to the enrollee. 
 
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 the appropriate outpatient code would be POS 32. 
 
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 90832 is "individual psychotherapy services rendered for 
30 minutes by a licensed mental health provider." 
 
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 medical 
records provided does not support Place of Service 32, which was submitted to the health plan as the place 
services were provided.  Medical records indicate Place of Service 31 - Skilled Nursing Facility - A facility 
which primarily provides inpatient skilled nursing care and related services to patients who require medical, 
nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital 
would be the appropriate Place of Service to submit for the services provided. Medicare rules state, provider 
must bill services correctly, which would include correct place of service. 
 
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 psychotherapy services (CPT 90832) provided to the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the shoulder orthosis provided on June 14, 2020. 
 
You asked the Plan to pre-approve the shoulder orthosis. You say that you were unable to obtain prior-
authorization at the time of service. The Plan denied your request. The Plan says the provider is not a network 
provider, these services are not urgent or emergent, nor were they 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 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 shoulder orthosis provided on June 14, 2020.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for a Biventricular ICD implant. 
 
You asked the Plan to pay for the Biventricular ICD implant. You say that you would like reconsideration 
because this service is medically necessary. The Plan denied your request. The Plan says that the information 
received is not sufficient to establish medical necessity. 
 
The Plan follows Medicare rules. Medicare rules say that evidence is sufficient to conclude that the use of 
ICDs, (also referred to as defibrillators) is reasonable and necessary for patients with specific conditions. 
 
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 Biventricular ICD implant. Our reviewer 
says that you have had multiple recurrent episodes of unexplained syncope, an episode of ventricular 
fibrillation requiring defibrillation without any other known cause including MI or prior ischemia. Our 
physician reviewer found you have been on guideline directed therapy for over 3 months with an EF of 30% 
and Class II CHF. You also meet medical necessity criteria for a Biventricular pacing ICD based on the 
published literature and guidelines. 
 
 
 
 
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 Biventricular ICD implant have been met. Therefore, we decided that the 
Plan has to pay for a Biventricular ICD implant. 
  
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two routine transportation trips to doctor's 
appointments. 
 
You asked the Plan to pre-approve two the routine transportation trips. The Plan denied your request. The Plan 
says routine transportation is not a covered benefit under your plan. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. The file shows the Plan does not have a 
routine transportation benefit. Therefore, we decided that the Plan does not have to pre-approve two routine 
transportation trips to doctor's appointments.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vaginectomy services coded 57110 provided on February 
25, 2020. 
 
You asked the Plan to pay for the vaginectomy services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 57110 is vaginectomy, complete removal of vaginal wall. 
 
We find that CPT code 57110 is not supported in the medical record. Specifically, this service is an inpatient 
only procedure. Based on this information, we decided that Medicare rules for coverage of the vaginectomy 
services have not been met. Therefore, we decided that the Plan does not have to pay for the vaginectomy 
services coded 57110 provided on February 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided on January 16, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for the inpatient hospitalization services. You say that the records provided should 
support the necessity of the service in dispute. The Plan denied your request. The Plan says the medical records 
provided does not support medical necessity for inpatient level of care. Enrollee's must receive their medical 
services from an in-network provider. Non-emergent services with non-contracted providers require prior 
authorization before services being rendered. 
 
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 at issue in this case is not a network provider with the Plan. The provider did not obtain prior 
authorization. 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 inpatient 
hospitalization services. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the review has determined that inpatient 
level of care services provided 11/16/20 was not medically necessary or reasonable. The enrollee did not 
require or receive any inpatient diagnostic studies or therapeutic interventions. 
 
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 inpatient hospitalization services have not been met.  
 
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 pay for the inpatient hospitalization services. Therefore, we decided 
that the Plan does not have to pay for the inpatient hospital services provided on January 16, 2020 by an out of 
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an orthopedic mattress. 
 
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 covered. 
 
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. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an orthopedic mattress.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) (64625). 
 
You asked the Plan to pre-approve RFA. You say that the services are necessary. The Plan denied your request. 
The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met. 
 
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 RFA. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found according to the literature, sacral lateral nerve branch blocks and/or ablations/neurotomies for 
the diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and investigational. 
Radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed 
radiofrequency, is considered investigational and therefore, not 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 RFA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve radiofrequency ablation (RFA) (64625).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no objective measurements or descriptions of the truncal, chest, or abdominal 
edema. 
 
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 device. Our reviewer says that the 
requested device is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee does not have lymphedema of the chest or trunk. One telemedicine note states she has 
secondary lymphedema toes to abdomen on 9/14/20. There are no measurements of these findings. The 
enrollee does not have unique characteristics that would indicate the segmented pump over a standard pump or 
documentation of trial and failure of a standard pump. 
 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office or other outpatient visit for the evaluation and 
management of a new patient (CPT Code 99203) provided from August 9, 2020, through September 11, 2020. 
 
You asked the Plan to pay for the services. You say that the service was only for an adjustment and do not feel 
you owe more since no other services were rendered. The Plan denied your request. The Plan says the services 
are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The request is for office visits provided by a chiropractor on multiple dates of service. The limited medical 
record indicates a diagnosis of intervertebral disc displacement of the thoracolumbar area. The Medicare rules 
say that ?Coverage extends only to treatment by means of manual manipulation of the spine to correct a 
subluxation?. ?All other services furnished or ordered by chiropractors are not covered. The records show that 
the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have 
to pay for office or other outpatient visit for the evaluation and management of a new patient (CPT Code 
99203) provided from August 9, 2020, through September 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgery to inject filling material (a substance used to fill 
in wrinkles and scars). 
 
You asked the Plan to pre-approve surgery to inject filling material. You say that the Plan denied your 
request. The Plan says Medicare does not cover cosmetic surgery, surgery to improve your appearance, under 
any circumstances. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of surgery to inject filling material have not been met. Therefore, we decided that 
the Plan does not have to pre-approve surgery to inject filling material (a substance used to fill in wrinkles and scars).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 power operated vehicle (K0800). 
 
You asked the Plan to pre-approve the group 1 power operated vehicle. You say that you would like 
reconsideration because this scooter is medically necessary. The Plan denied your request. The Plan says the 
home assessment is incomplete and there is no record of the member's old scooter. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 group 1 power operated vehicle. 
Our reviewer says that the member's mobility deficit is currently helped by a walker and scooter. There was no 
assessment of whether he was able to use a manual wheelchair. Our physician reviewer found the 
documentation reveals no in home assessment with objective measurements to evaluate whether the member 
can safely maneuver the requested scooter in the home. 
 
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 group 1 power operated vehicle have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 1 power operated vehicle (K0800).