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

 
We decided that the Plan does not have to pre-approve office visits and telemedicine to be provided by an out 
of network provider and pay for the telemedicine service provided on April 20, 2020. 
 
You asked the Plan to pre-approve office visits and telemedicine or pay for the telemedicine service. You say 
that this provider is the only one who can treat your medical condition. The Plan denied your request. The Plan 
says they have in network providers who can provide this service. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve office 
visits and telemedicine to be provided by an out of network provider or pay for the telemedicine service 
provided on April 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cerebral perfusion analysis (0042T) provided on February 
14, 2020. 
 
You asked the Plan to pay for cerebral perfusion analysis. You say that this should be covered. The Plan denied 
your request. The Plan says this is a non-covered code. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT Category III Code 0042T is noncovered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of cerebral perfusion analysis have not been met. Therefore, we decided that the Plan does not have to 
pay for cerebral perfusion analysis (0042T) provided on February 14, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee and billed under 
code 88341. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says code 88341 was not billed with an appropriate primary code and is not eligible for 
payment to the same practitioner for the same patient on the same date of service.  
 
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, this claim cannot be paid as billed 
due to an issue with the primary code. Therefore, we decided that the Plan does not have to pay for physician 
services provided to the enrollee and billed under code 88341.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (G0249) provided on February 20, 2020, and 
February 25, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the frequency limit 
was exceeded. 
 
The Plan must follow Medicare rules. Medicare rules say that code G0249 is covered once every 25 days.  
 
We looked at the file and Medicare rules. The records show that code G0249 was paid for date of service 
February 14, 2020. The requested services were provided less than 25 days after the paid 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 (G0249) provided on February 20, 2020, and 
February 25, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 8, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the place of service code on the claim does not 
reflect the location of where the specimen was obtained. 
 
The Plan must follow Medicare rules. Medicare rules say that place of Service (POS) code is generally used to 
reflect the actual setting where the beneficiary receives the face to-face service.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, the claim submitted was billed with a 
laboratory place of service code. The records indicate that this specimen was not obtained in the laboratory. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on May 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Decipher prostate biopsy. 
 
You asked the Plan to pre-approve the biopsy. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
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 biopsy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the medical records indicate that this enrollee has stage T1c Gleason's grade 3+3 adenocarcinoma 
(grade group 2) with a PSA of 5.5 ng/mL which is considered very low risk disease. Decipher prostate biopsy 
is indicated for patients with unfavorable risk disease. 
 
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 biopsy have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Decipher prostate biopsy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the specialty crown (D9999) and the infection 
control (D9999) provided. 
 
You asked the Plan to reimburse you for the dental services. You say that you followed the instructions. You 
also say that you should be reimbursed for these services. The Plan denied your request. The Plan says there is 
an $850 allowance every year for non-Medicare covered preventive and comprehensive dental services 
combined. The Plan also says that this benefit has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the annual allowance of $850 has been 
exhausted. 
Date of Service CPT Code Billed Amount Plan Paid Your Responsibility 
6/8/2020 D4910 $15 $15 $0 
6/30/2020 D9310 $65 $65 $0 
 D3320 $175 $175 $0 
7/7/2020 D2740 $500 $500 $0 
 D2954 $95 $95 $0 
 D9999 $400 $0 $400 
 D9999 $15 $0 $15 
TOTAL:   $850 $415 
Therefore, we decided that the Plan does not have to reimburse you for the specialty crown (D9999) and the 
infection control (D9999) provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric services. 
 
You asked the Plan to pre-approve the inpatient psychiatric services. You say that the client's admission and 
continuing care clinicals support the need for additional care. The Plan denied your request. The Plan says 
inpatient rehab is only covered in an inpatient hospital. The Plan says that the requested provider is a free-
standing psychiatric facility. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
service furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. 
Medicare rules also say that Substance Abuse Facilities are not eligible to enroll in Medicare. 
 
We looked at the file and Medicare rules. The records show that the facility you are requesting the enrollee 
receive inpatient rehabilitation treatment from is not an inpatient hospital, but rather a substance abuse facility. 
This would mean that the facility is ineligible to enroll in Medicare and is not eligible for payment. Based on 
this information, we decided that Medicare rules for coverage of the inpatient psychiatric services have not 
been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the duplex scan and echocardiography 
provided on June 17, 2020 and June 18, 2020. 
 
You asked the Plan to waive the copayment for the duplex scan and echocardiography. You say that the 
cardiology tests weren't covered because they looked as if they were out-of-network. You say that $250 is 
owed to you. The Plan denied your request. The Plan says the copayments 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 $125 
copayment for each Medicare-covered radiological diagnostic service.  
 
You have been asked to pay a $125 copayment for the duplex scan and a $125 copayment for the 
echocardiography.  
 
Date of Service Service Standard Copayment Plan Paid Member Liability 
June 17, 2020 Duplex Scan $125 $71.40 $125 
June 18, 2020 Echocardiography $125 $80.06 $125 
TOTAL:    $250 
 
The duplex scan and echocardiography fall within the "Outpatient Diagnostic Tests and Therapeutic Services 
and Supplies" benefit category. The records show that the claim was processed as in-network.  
  
 
 
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 duplex scan and echocardiography provided on June 17, 
2020 and June 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you have been receiving chemotherapy since 
November 2019, and you often get nauseous and have fallen in the shower before. You truly need this shower 
chair to feel secure while showering. The Plan denied your request. The Plan says this is not an item that can be 
covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance and the deductible for the immune globulin 
injection (J1559) and home infusion therapy (S9379) provided on July 15, 2020. 
 
You asked the Plan to waive the coinsurance and the deductible for the immune globulin injection and home 
infusion therapy. You say that since this is a home infusion therapy you should be covered in full after meeting 
the deductible. The Plan denied your request. The Plan says the coinsurance applied correctly in this case. 
 
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 10% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 10% coinsurance for the immune globulin injection. The service provided falls 
within the Medicare Part B prescription drugs benefit category and not the home infusion therapy 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.  
 
 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $300 deductible for home infusion therapy.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category home 
infusion therapy. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 
deductible for home infusion therapy. This cost sharing is a contractual obligation that had not been met at the 
time home infusion therapy (S9379) was received on July 15, 2020. 
 
Therefore, we decided that the Plan does not have to waive the coinsurance and the deductible for the immune 
globulin injection (J1559) and home infusion therapy (S9379) provided on July 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the head/brain. 
 
You asked the Plan to pre-approve a CT scan. The Plan denied your request. The Plan says a CT scan is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 a CT scan. Our reviewer says that the 
requested CT scan is not medically reasonable and necessary. Our physician reviewer found that the 
performance of neuroimaging is not generally recommended in primary headache syndromes, in the absence of 
focal neurological findings. There were no such findings noted in the clinical information provided for review. 
Furthermore, in terms of neuroimaging for headaches, it is generally preferable to have a patient undergo MRI 
(when possible) rather than a CT scan, given that MRI is of more diagnostic utility.  The enrollee is not 
otherwise noted to have any contraindications precluding performance of a MRI. In as much, it cannot be said 
that there is sufficient literature available to permit a determination that the requested CT scan is 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 a CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a CT scan of the head/brain.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on April 15, 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 code 22853 is 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 22853 is insertion of interbody biomechanical device(s) 
(eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), 
when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List 
separately in addition to code for primary procedure). 
 
We find that CPT code 22853 is not supported in the medical record. Specifically, there is no documentation of 
insertion of an interbody biomechanical device. 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 
surgical services rendered on April 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power operated vehicle (K0806) for the 
enrollee. 
 
You asked the Plan to pre-approve a Group 2 power operated vehicle. You say that this would benefit the 
enrollee. The Plan denied your request. The Plan says that this is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Group 2 POVs are denied as not reasonable and 
necessary.  
 
The item at issue is a Group 2 POV. This item is denied by Medicare for all indications. This means that 
Medicare rules for coverage of the POV have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Group 2 power operated vehicle (K0806) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on July 6, 2020.  
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says a modifier is required on the claim to show this was a separate and distinct service from 
one previously billed by the same physician group. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes and when required the appropriate modifier. In this 
case, the same service was previously paid to a provider within the same physician group. The claim submitted 
does not contain a modifier to show this was a separate and distinct services. Medicare billing criteria are not 
met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on 
July 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove a therapeutic continuous glucose monitor (CGM) 
 
You asked the Plan to preapprove the CGM. You say that the CGM should be authorized. The Plan denied your 
request. The Plan says the enrollee only tests once a day and does not take insulin. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, or require frequent 
self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we 
decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan 
does not have to preapprove a therapeutic continuous glucose monitor (CGM)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inflatable bathtub (easy bath) (E1399). 
 
You asked the Plan to pre-approve inflatable bathtub. You say that you are pending surgery and is trying to get 
ready before surgery and make things easier for your caregiver and yourself. The Plan denied your request. The 
Plan says this item is not covered because it is not medical in nature. 
 
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 inflatable bathtub (easy bath) (E1399).
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for critical care services (99291) provided on December 5, 2019. 
 
You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says that the documentation does not note the 
amount of time spent providing the critical care services. 
 
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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-
74 minutes. 
 
We find that CPT code 99291 is supported in the medical record. Specifically, the documentation clearly states 
that 32 minutes were spent rendering critical care services on the billed date of service. Based on this 
information, we decided that Medicare rules for coverage of the critical care services have been met. Therefore, 
we decided that the Plan has to pay for critical care services (99291) provided on December 5, 2019.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan 
denied your request. The Plan says your needs can be met at a different level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the medical records provided the complexity of the enrollee's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an 
IRF level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.