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

 
We decided that the Plan does not have to pay for radiology services (CPT 70551) provided to the enrollee on 
December 4, 2019. 
 
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 this did not include the appropriate primary, first-listed or principal diagnosis code. 
 
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 70551 is "Magnetic resonance (eg, proton) imaging, brain 
(including brain stem)." 
 
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 per CPT 
guidelines, ICD 10 I92 Toxic Encephalopathy has instruction for "Code First", if applicable, drug induced 
(T36-T50) or use (T51-T65) to identify toxic agent. Documentation did not include an appropriate primary 
diagnosis. 
 
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 radiology services (CPT 70551) provided to the enrollee on December 4, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says the doctor will need to provide notes that explain the different non-injection therapies 
that were tried, and the results. 
 
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 injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no documentation of physical exam findings supportive of the diagnosis of sacroilitis. There is 
no documentation of an NSAID trial or a physical therapy trial. There is no imaging of the SI joint. The lack of 
conservative therapy does not meet the criteria. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac joint injection for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided during the hospital stay 
from July 28, 2020, to July 31, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that you were not told that you would not 
be able to take the medication you brought from home. The Plan denied your request. The Plan says the 
medications are covered under Part D and no reimbursement is due under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided during the hospital stay from July 28, 2020, to July 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of residual tooth rots (D7250), unspecified 
preventative procedure (D1999), and limited oral evaluation (D0140) provided on August 31, 2020. 
 
You asked the Plan to pay for the removal of residual tooth rots, unspecified preventative procedure, and 
limited oral evaluation. You say that you would like this claim reprocessed and approved for payment. The 
Plan denied your request. The Plan says you have exhausted your benefit for oral exams and the Plan does not 
cover the removal of residual tooth rot and unspecified preventative procedure. 
 
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. The Plan covers two oral 
exams once a year. 
 
We looked at the file and Medicare rules. The file indicates that you previously had two oral exams covered by 
the Plan. Therefore, a third oral exam will not be covered since you have exhausted this benefit. Based on this 
information, we decided that the Plan's rules for coverage of the limited oral evaluation have not been met. 
 
Furthermore, though the Plan offers a dental benefit in excess of Medicare coverage, the removal of residual 
tooth rots and unspecified preventative procedure are not among those covered under this benefit. Therefore, 
we decided that the Plan does not have to pay for the removal of residual tooth rots (D7250), unspecified 
preventative procedure (D1999), and limited oral evaluation (D0140) provided on August 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone allograft (20930) provided on June 15, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says based upon Medicare guidelines, payment is 
bundled and no additional reimbursement should be made. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
We find that CPT code 20930 is not supported in the medical record. Specifically, CPT code 20930 has a status 
indicator of B in the Physician Fee Schedule. This means that payment for this service is bundled in payment 
for other services provided. Based on this information, we decided that Medicare rules for coverage of this 
service have not been met. Therefore, we decided that the Plan does not have to pay for the bone allograft 
(20930) provided on June 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an advanced leg pump 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 is no documentation of a four-week trial of a basic lymphedema pump with 
detailed measurements provided. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no evidence of lymphedema of the chest, trunk, or abdomen. The enrollee does not have unique 
characteristics that would indicate the segmented pump over a standard pump. There is no documentation of a 
four week trial and failure of the standard pump with detailed measurements. 
 
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 an advanced leg pump device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit received on August 3, 2020. 
 
You asked the Plan to pay for the visit. You say that this should be paid for. The Plan denied your request. The 
Plan says the services were not referred by a network provider or rendered in a participating facility. 
 
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 rendering 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 an office visit received on August 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray rendered on May 12, 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 code 71045 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 71045 and 32555. Code 71045 is a column II code with a 
modifier indicator of 1 when billed with column I code 32555. Code 71045 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the chest 
x-ray rendered on May 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood glucose monitor and supplies (E0607, A4253 and 
A4259) provided on April 14, 2020, through July 13, 2020. 
 
You asked the Plan to pay for the blood glucose monitor and supplies. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation 
submitted does not include an itemized billing/shipping invoice to verify the delivered supplies. 
 
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 valid proof of delivery for the supplies provided in this case. Specifically, the 
record does not include an itemized billing/shipping invoice to verify the supplies that were delivered. 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 the blood glucose monitor and supplies (E0607, 
A4253 and A4259) provided on April 14, 2020, through July 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a walker purchased on August 22, 2020.

You asked the Plan to pay for walker. You say that the enrollee needed this walker and did not realize that prior authorization was needed. The Plan denied your request. The Plan says the denial of payment for this item is correct, because this provider is not eligible for payment.

The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered items, a provider or supplier must be enrolled in the Medicare program. 

We looked at the file and Medicare rules. This provider is not enrolled in the Medicare program and is not eligible for payment. Based on this information, we decided that Medicare rules for coverage of walker have not been met. Therefore, we decided that the Plan does not have to pay for a walker purchased on August 22, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for physical therapy provided on January 3, 2020. 
 
You asked the Plan to waive the cost for physical therapy. You say that you were charged a copayment and you 
paid it. You say that you don't believe you owe for this situation. The Plan denied your request. The Plan says 
the cost share applied correctly. 
 
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 your deductible amount for Medicare Part B services is $198. Until you have 
paid the deductible amount, you must pay the full cost for Medicare Part B services. Your contract with the 
Plan says that enrollees must pay 20% coinsurance for each Medicare-covered physical therapy and speech-
language therapy visit.  
 
The item or service you asked the Plan to waive the cost for falls within the "Outpatient Rehabilitation 
Services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your 
$198 deductible applies to outpatient rehabilitation services. This cost sharing is a contractual obligation that 
had not been met at the time physical therapy was received on January 3, 2020. Therefore, $41.39 has been 
applied to meet your deductible. 
  
Since your $198 deductible was met, you have also been asked to pay $15.47, which is 20% of the allowed 
amount for the physical therapy. The allowed amount is $77.36 (20% x $77.36 = $15.47). 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 cost for physical therapy provided on January 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the 
porcelain/ceramic crown (D2740) provided on July 8, 2020, by a provider who has opted out of Medicare. 
 
You asked the Plan to pay for the limited oral evaluation and the porcelain/ceramic crown. You say that you 
were not aware this provider does not accept Medicare. The Plan denied your request. The Plan says you will 
be fully responsible for all dental services from a provider who has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the limited 
oral evaluation (D0140) and the porcelain/ceramic crown (D2740) provided on July 8, 2020, by a provider who 
has opted out of Medicare.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided from June 20, 2020, 
through June 30, 2020. 
 
You asked the Plan to pay for the outpatient hospital services. The Plan denied your request. The Plan says the 
plan will generally cover your medical care as long as you receive your care from a provider who is eligible to 
provide services under Original Medicare. The enrollee can receive your care from either a network provider or 
an out-of-network provider. Except for emergency care, we cannot pay a provider who is not eligible to 
participate in Medicare.  
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for outpatient hospital services provided from June 20, 2020, 
through June 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on August 28, 
2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you thought that the copayment 
was waived. 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 $40 
copayment for specialist visits.  
 
You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctor's office visits 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 a specialist visit provided on August 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 7, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you would like reconsideration because the services 
rendered were medically necessary. The Plan denied your request. The Plan says prior authorization was not 
obtained by the provider or facility. 
 
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 October 7, 2020 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a 
participating provider on October 14, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that all the doctor said to you 
was that you had a rash. You say that you do not feel like this warrants a 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 $35 
copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a $35 copayment for a specialist office visit. Since a specialist office visit was 
provided, the correct copayment has been applied. A specialist office visit falls within the 
physician/practitioner services/specialist 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 a specialist office visit provided by a participating provider on October 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance and preventive procedure 
provided on August 27, 2020. 
 
You asked the Plan to pay for the periodontal maintenance and preventive procedure. You say that the Plan you 
have includes dental coverage. You also say that you have not been able to find a Medicare dentist in your 
region. The Plan denied your request. The Plan says the treating provider opted out of Medicare effective April 
21, 2015, to April 21, 2021. The Plan also says that you are fully responsible for all dental services from a 
provider who has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
periodontal maintenance and preventive procedure provided on August 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections and lab services (64640, 77002, 80305, J3301) 
provided February 12, 2020 
 
You asked the Plan to pay for the injections and lab services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the documentation does not support the services 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. 
 
We find that CPT codes 64640, 77002, 80305, & J3301 are not supported in the medical record. Specifically, 
the procedure report documents Geniculate Radiofrquency Ablation. When performing a RFA on Genicular 
nerves, providers must report CPT 64624. Documentation did not include a drug testing report to confirm this 
service was performed. Documentation does not support CPT code J3301. Add-on code 77002 is not 
supported. Based on this information, we decided that Medicare rules for coverage of the injections and lab 
services have not been met. Therefore, we decided that the Plan does not have to pay for injections and lab 
services (64640, 77002, 80305, J3301) provided February 12, 2020