Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy services (97165) provided on April 2, 
2019. 
 
You asked the Plan to pay for the occupational therapy services. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the submitted claim does not 
include the required modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that the claim must include a GN, GO or GP modifier. 
 
We find that CPT code 97165 is not supported in the medical record. Specifically, CPT code 97165 was not 
billed with the required therapy modifier. Based on this information, we decided that Medicare rules for 
coverage of the occupational therapy services have not been met. Therefore, we decided that the Plan does not 
have to pay for occupational therapy services (97165) provided on April 2, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy (90837) provided by a Marriage Family 
Therapist from June 15, 2019, to July 8, 2019. 
 
You asked the Plan to pay for psychotherapy. You say that this should be covered. The Plan denied your 
request. The Plan says the provider you received this service from is not eligible for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. Marriage Family Therapist are not eligible to enroll in Medicare. 
 
We looked at the file and Medicare rules. The provider you received the services at issue from is a Marriage 
Family Therapist and is not eligible to enroll in Medicare. Based on this information, we decided that Medicare 
rules for coverage of psychotherapy have not been met. Therefore, we decided that the Plan does not have to 
pay for psychotherapy (90837) provided by a Marriage Family Therapist from June 15, 2019, to July 8, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for post-stabilization inpatient care provided February 9, 2019 to 
February 10, 2019. 
 
You asked the Plan to pay for the post-stabilization inpatient care. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the enrollee was stable for transfer to a plan facility.
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 post-stabilization inpatient care. Our 
reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee was 
stable and appropriate for ambulance transport with monitoring to a Plan facility for observation/admission 
level of care after the emergency room evaluation. 
 
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 post-stabilization inpatient care have not been met. Therefore, we decided 
that the Plan does not have to pay for post-stabilization inpatient care provided February 9, 2019 to February 
10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating 
provider on March 10, 2020. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you cannot afford this. The Plan 
denied your request. The Plan says the correct coinsurance has been applied. 
 
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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed 
amount is $18.86. The total amount you are being asked to pay is $3.77 ($18.86 x 20% = $3.77). An 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 an injection provided by a participating provider on March 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on 
April 10, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says there is no itemized billing/shipping invoice to verify the services billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a proof of delivery to support medical necessity for the supplies provided in this 
case. There is no itemized billing/shipping invoice to verify the services billed. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on April 10, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the cerebral perfusion mapping provided on May 14, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this is not 
medically necessary. 
 
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 pay for the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the symptoms of left sided weakness and speech disorder are very suspicious for stroke or CVA. As 
such, the quantification of cerebral blood flow which analyzes the penumbra or brain matter at risk with 
ischemia is part of the stroke protocol utilized at centers with state of the art stroke diagnosis and treatment. 
This procedure is valid and not experimental, and should be considered 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 the services have been met. Please note that the LCD the Plan is not applicable 
for the jurisdiction in question. Therefore, we decided that the Plan has to pay for the cerebral perfusion 
mapping provided on May 14, 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 waive the copayment for the physician visit you had at an outpatient 
hospital clinic on May 15, 2020. 
 
You asked the Plan to waive the copayment for the physician visit at an outpatient hospital clinic. You say that 
you shouldn't have to pay this copayment since you had to go to the hospital clinic since your PCP's office was 
closed. 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 $25 
copayment for specialist physician services at a hospital-owned clinic.  
 
You have been asked to pay a $25 copayment for the physician visit at an outpatient hospital clinic. Because 
the doctor you saw there was not your primary care physician (PCP), they are considered a specialist. That is 
why the physician visit you had at an outpatient hospital clinic falls within the specialist physician services at a 
hospital-owned clinic 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 
physician visit you had at an outpatient hospital clinic on May 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6539. 
 
You asked the Plan to pre-approve the compression stockings. You say that the claim should be paid for the 
condition. The Plan denied your request. The Plan says they are examples of wound care items which are 
non-covered under the surgical dressing benefit because they do not meet the statutory definiOon of a dressing. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6539 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6539.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Superion interspinous device (22869, 22870). 
 
You asked the Plan to pre-approve a Superion interspinous device. 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 a Superion interspinous device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found current evidence based medical guideline and peer reviewed literature do 
not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. 
There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for 
this enrollee's medical condition. FDA indications include implantation of the Superion device at one or two 
adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no 
more than two levels, from L1 to L5. This enrollee has severe foraminal stenosis at L4/5 that would not meet 
FDA indications. FDA contraindications include osteoporosis, that has not been adequately addressed in the 
medical records. There is no discussion indicating that a DEXA scan has demonstrated no osteoporosis in this 
76-year-old male. Superion indirect lumbar decompression would not be considered the standard of care for the 
enrollee's medical condition. Therefore, this request for Superion procedure at L3/4 and L4/5 does not meet 
Medicare criteria as medically reasonable and necessary for treatment of this enrollee's medical condition. 
 
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 Superion interspinous device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Superion interspinous device (22869, 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent limb compression device. 
 
You asked the Plan to pay for intermittent limb compression device. You say that the claim should be paid The 
Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for when 
there is no documentation of lymphedema, chronic venous insufficiency with venous stasis ulcer or any 
treatment of such. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression 
device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular stimulator, electronic shock unit (E0745) 
provided March 15, 2020. 
 
You asked the Plan to pay for the neuromuscular stimulator. You say that please see attached medical records 
and supporting documents confirming medical necessity. The Plan denied your request. The Plan says there is 
no actual physical exam, all information was provided over the phone, there is no evidence of an established 
relationship between the enrollee and the ordering physician, there are no clinical notes from the enrollee's 
primary health provider, and the enrollee is not in an eligible geographical area for telehealth services. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the neuromuscular 
stimulator, electronic shock unit (E0745) provided March 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intradialytic parenteral nutrition (IDPN). 
 
You asked the Plan to pre-approve IDPN. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that IDPN is covered when specific criteria is 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 pre-approve IDPN. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the review has determined that in this case, 
the enrollee does not meet the national guidelines Nutritional Support Clinical Policy Bulletins Medical 
Clinical Policy Bulletins Number: 0061. There is no new clinical information showing that the enrollee's total 
protein is less than 6, albumin is less than 3.4, or that the enrollee has lost more than 10% of their body weight 
over three months. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IDPN have not been met. Therefore, we decided that the Plan does not have to 
pre-approve intradialytic parenteral nutrition (IDPN).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a 
participating provider on June 27, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you do not feel like you 
received enough care to have this copayment. The Plan denied your request. The Plan says the correct 
copayment has been applied. 
 
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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for an emergency room visit. Since an emergency room visit was 
provided, the correct copayment has been applied. An emergency room visit falls within the emergency 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 an emergency room visit 
provided by a participating provider on June 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services, first 15 minutes (99152) 
provided February 7, 2020. 
 
You asked the Plan to pay for moderate sedation services. You say that you are appealing the decision and 
request reconsideration of the attached claim that was denied. The Plan denied your request. The Plan says the 
records do not support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the documentation submitted 
did not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level 
of consciousness and physiological status. Of note, an independent trained observer is someone other than the 
physician performing the services. Based on this information, we decided that Medicare rules for coverage of 
moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for 
moderate sedation services, first 15 minutes (99152) provided February 7, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve continued physical therapy services. 
 
You asked the Plan to pre-approve continued physical therapy services. You say that physical therapy services 
are necessary for recovery. The Plan denied your request. The Plan says that rules for coverage for physical 
therapy services have not been met. 
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We have reached out to the Plan for the necessary information and have not 
received a substantive response. We find that the Plan has not provided sufficient records to support its 
decision to deny continued physical therapy services. Therefore, we decided that the Plan has to pre-approve 
continued physical therapy services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Superion interspinous spacer (22869, 22870). 
 
You asked the Plan to pre-approve a Superion interspinous spacer. 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 a Superion interspinous spacer. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the spacer remains experimental. More research is needed to show safety 
and efficacy. 
 
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 Superion interspinous spacer have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Superion interspinous spacer (22869, 22870).