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

We decided that the Plan has to pre-approve shoulder surgery. 
 
You asked the Plan to pre-approve shoulder surgery. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says that the requested services are 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 pre-approve shoulder surgery. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee presents with a one-year history of left shoulder pain. The enrollee reported pain at 
nighttime and difficulty with certain shoulder positions. Clinical exam findings have documented full range of 
motion, positive impingement signs, and left AC joint tenderness. There is imaging evidence of AC joint 
arthrosis with encroachment anatomy and rotator cuff tendinosis. Conservative treatment has included 
subacromial bursa and subacromial space injections, physical therapy, and NSAIDs. Under consideration is a 
request for left shoulder arthroscopic distal clavicle resection and subacromial decompression. Both areas are 
reasonably documented to contribute to ongoing painful impingement syndrome. Current evidence based 
medical literature would support the recommended surgery in the presence of significant clinical findings 
relative to the acromioclavicular joint, including positive tenderness. Additionally, the subacromial injection 
trial of cortisone would have been expected encompass the distal clavicle, and was not efficacious permanently. 
Therefore, the enrollee does have a diagnosis, condition and/or symptoms that meet the Medicare criteria for 
left shoulder arthroscopic distal clavicle resection or subacromial decompression at this time. Therefore, this 
request for left shoulder arthroscopic distal clavicle resection and subacromial decompression is considered the 
standard of care and medically reasonable and necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of shoulder surgery have been met. Therefore, we decided that the Plan has to pre-
approve shoulder surgery.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiofrequency ablation. 
 
You asked the Plan to pay for radiofrequency ablation. You say that you are asking for reconsideration of the 
decision to deny this treatment option as the enrollee has failed a multitude of other treatments and is no longer 
a candidate for many others. The Plan denied your request. The Plan says the records provided does not support 
that the enrollee meets the Medicare criteria. 
 
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 pay for radiofrequency ablation. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case, there is no documentation provided indicating that the previous two 
MBBs provided 80% or more pain relief for the duration of the agent used.  The medical records provided do 
not meet the requirements listed in the LCD for Medicare coverage. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pay for radiofrequency ablation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reblozyl. 
 
You asked the Plan to pre-approve the Reblozyl. You say that the records provided support the need for the 
requested drug. The Plan denied your request. The Plan says the clinical criteria for coverage have not been 
met. The Plan says that the use of the requested drug requires failure of an erythropoiesis stimulating agent and 
requiring 2 or more red blood cell units over 8 weeks. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Reblozyl. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found The requested use of Reblozyl is not 
FDA approved for the enrollee's diagnosis. FDA approval for the treatment of anemia failing an erythropoiesis-
stimulating agent and requiring 2 or more RBC units over 8 weeks in adults with very low to intermediate-risk 
myelodysplastic syndromes with ring sideroblasts (MDS-RS) or with myelodysplastic/myeloproliferative 
neoplasm with ring sideroblasts and thrombocytosis (MDS/MPN-RS-T). The use of the requested drug is not 
supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical 
journal. 
 
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 Reblozyl have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Reblozyl.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skin grafting services provided to the enrollee on December 
11, 2019. 
 
You asked the Plan to pay for codes 15271-78 and 10060-78. We are dismissing the request for codes 44120 
and 49553 as these were approved by the Plan. You say that this claim should be paid. The Plan denied your 
request. The Plan says while a portion of this claim was paid, the operative report did not include 
documentation of an application of a skin substitute graft to the trunk, arms or legs for a total wound surface 
area up to 100 sq cm, for the first 25 sq cm or less wound surface area; therefore, code 15271-78 cannot be 
verified. In addition, regarding code 10060-78, this code was inappropriately billed based on Medicare 
guidelines. The Plan stated that the guidelines indicate that when codes 10060 or 10061 is performed with 
another separately identifiable procedure, the highest dollar value code is listed as the primary procedure and 
subsequent procedures are appended with modifier 51.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. Review of the limited medical records provided does 
not confirm codes 15271 and 10060 were billing appropriately.  
  
Therefore, we decided that the Plan does not have to pay for skin grafting services provided to the enrollee on 
December 11, 2019 and billed under codes 15271-78, 10060-78.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial nursing facility care rendered on May 28, 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 the claim was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that a physician/practitioner/supplier furnishing services to 
a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital POS code 21.
 
We looked at the file and Medicare rules. The file shows that procedure code 99306 was billed with POS code 
21 for an inpatient hospital. This POS is inappropriate, as the services were rendered in a skilled nursing 
facility. 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 initial nursing facility care rendered on 
May 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 13, 2020 by an OON 
provider. 
 
You asked the Plan to pay for the outpatient office visit and services. You say that the office visit does not 
require an authorization. The Plan denied your request. The Plan says the services were rendered by a non-
participating provider. The Plan also says that 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 the medical services provided on May 13, 2020 by 
an OON provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency department services 
provided on October 11, 2019, October 30, 2019, and January 26, 2020. 
 
You asked the Plan to waive the copayment for the emergency department services. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were 
processed correctly per your plan benefits. 
 
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 each of the emergency room visits. The emergency room 
visits fall 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 
the emergency department services provided on October 11, 2019, October 30, 2019, and January 26, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the physical therapy (PT) services provided 
on July 16, 2020. 
 
You asked the Plan to waive the deductible for the PT services. You say that you were told you only had a $25 
copayment for these services. The Plan denied your request. The Plan says you had not yet met your deductible 
when you received these PT services. The Plan also says that their customer service phone records do not show 
you were ever quoted any cost sharing amounts related to PT. 
 
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 $750 deductible that applies to PT services. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $750 deductible. This cost sharing is a 
contractual obligation that had not been met at the time the PT services was received on July 16, 2020. 
Therefore, we decided that the Plan does not have to waive the deductible for the physical therapy (PT) 
services provided on July 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on August 19, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 office visit provided on August 19, 2019 by an 
out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergent ambulance transportation 
service (A0429) provided on May 9, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $265 
copayment for each covered, one-way ambulance trip by ground or water.  
 
You have been asked to pay a $265 copayment for the one-way ground ambulance trip provided. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the emergent ambulance transportation service (A0429) provided on 
May 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CTA of the chest (71275) and CTA of the abdomen 
and pelvis (74174). 
 
You asked the Plan to pre-approve a CTA of the chest (71275) and CTA of the abdomen and pelvis (74174). 
You say that the requested CTA of the chest (71275) and CTA of the abdomen and pelvis (74174) are 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested CTA of the chest (71275) and the requested CTA of the abdomen and pelvis (74174) 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 a CTA of the chest (71275) and CTA of 
the abdomen and pelvis (74174). Our reviewer says that the enrollee does not meet criteria for the requested 
CTA of the chest (71275) and the requested CTA of the abdomen and pelvis (74174) is not medically 
necessary. Our physician reviewer found the enrollee is with a complex cyst in her right breast. She has a 
history of hypertension and end-stage renal disease. The documentation in the case file is insufficient to 
demonstrate that the enrollee has a covered indication for the requested CTA of the chest. The documentation 
in the case file is insufficient to demonstrate that the enrollee has a covered indication for the requested CTA of 
the abdomen and pelvis. 
 
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 CTA of the chest (71275) and CTA of the abdomen and pelvis (74174) have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a CTA of the chest (71275) and 
CTA of the abdomen and pelvis (74174).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services (97163) provided on July 24, 2020. 
 
You asked the Plan to pay for the physical therapy services. You say that you would like reconsideration 
because the services rendered were medically necessary. The Plan denied your request. The Plan says the 
submitted code does not appropriately reflect the services provided by the physical therapy assistant. 
 
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 97163 is physical therapy evaluation: high complexity, 
requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities 
that impact the plan of care; An examination of body systems using standardized tests and measures addressing 
a total of 4 or more elements from any of the following: body structures and functions, activity limitations, 
and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and 
Clinical decision making of high complexity using standardized patient assessment instrument and/or 
measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient 
and/or family.  
 
We find that CPT code 97163 is not supported in the record. Specifically, the record indicates that these 
services were rendered by a physical therapy assistant. It is inappropriate to bill the services of a physical 
therapy assistant incident to a physician's services. Based on this information, we decided that Medicare rules 
for coverage of the physical therapy services have not been met. Therefore, we decided that the Plan does not 
have to pay for physical therapy services (97163) provided on July 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for vision care provided on July 27, 2020. 
 
You asked the Plan to waive the copayment for vision care. You say that you received a diabetic eye exam and 
should not owe a copayment. 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 $50 
copayment for each exam to diagnose and treat diseases and conditions of the eye a $0 copayment for annual 
glaucoma screenings, eyewear after cataract surgery and annual diabetic retinopathy screenings for vision care.  
 
The medical records show that you received an eye exam to diagnose and treat diseases and conditions of the 
eye on July 27, 2020. Therefore, you are responsible to pay the $50 copayment.  
 
You have been asked to pay a $50 copayment for vision care. Vision care falls within the vision 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 vision care provided on July 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walking boot provided on November 11, 2019. 
 
You asked the Plan to pay for the walking boot. You say that the Plan should pay this claim. The Plan denied 
your request. The Plan says the billed item was denied because it was not reported with a required modifier. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a KX modifier if the 
coverage criteria is met.   
 
For a beneficiary?s equipment to be eligible for reimbursement the reasonable and necessary (R&N) 
requirements set out in the related Local Coverage Determination must be met. There is no modifier on the 
claim. Based on this information, we decided that Medicare rules for coverage of a walking boot have not been 
met. Therefore, we decided that the Plan does not have to pay for the walking boot provided on November 11, 
2019.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient office visit (99203) provided 
March 17, 2020. 
 
You asked the Plan to waive the copayment for the outpatient office visit. You say that you feel you should not 
have to pay for the visit since you went in for COVID testing. That was the reason for the visit. The provider 
could not change the coding for the visit since you were not tested. The Plan denied your request. The Plan 
says the claim processed with the correct copayment 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 $50 
copayment per visit for Urgently needed services.  
 
You have been asked to pay $50 copayment per visit for the outpatient office visit. the outpatient office visit 
falls within the Urgently needed services benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for outpatient office visit (99203) provided March 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit provided on December 9, 2019 by 
an OON provider. 
 
You asked the Plan to pay for the outpatient office visit. You say that you were unaware that you were still 
OON. The Plan denied your request. The Plan says the services were rendered by a non-contracted provider. 
The Plan also says that the enrollee self-referred to the non-contracted provider's office, and 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 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 outpatient office visit provided on December 
9, 2019 by an OON provider.