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

 
We decided that the Plan does not have to waive the coinsurance for the Euflexxa injections you received from 
April 20, 2020, to May 4, 2020. 
 
You asked the Plan to waive the coinsurance for the injections. You say that these injections were done by the 
doctor's assistant, so any cost sharing after the first visit isn't justified. The Plan denied your request. The Plan 
says it has reprocessed your claims and they are no longer charging you specialist visit copayments for these 
dates of service.  However, the Plan says that you have been charged the coinsurance for the injections 
appropriately. 
 
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 20% 
coinsurance for all drugs covered under Medicare Part B.  
 
You have been asked to pay 20% coinsurance for the injections. The injections fall within the drugs covered 
under Medicare Part B 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 the 
Euflexxa injections you received from April 20, 2020, to May 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wrist x-ray provided on June 14, 2020. 
 
You asked the Plan to pay for the x-ray. The Plan denied your request. The Plan says an appropriate modifier is 
needed to represent the services as separate and distinct. 
 
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 73100 is radiologic examination, wrist; 2 views. We find 
that CPT code 73100 is not supported. Specifically, the service at issue was not billed with a valid modifier for 
separate payment. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the wrist x-ray provided on June 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs 
provided. 
 
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. You say that you disagree 
with the charges. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You received Medicare Part B prescription drugs on March 31, 2020. The total allowed amount is $1,075.87 
and 20% of that is $215.17.  
 
You have been asked to pay the total coinsurance amount of $215.17 for Medicare Part B prescription drugs. 
Medicare Part B prescription drugs fall 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 Medicare Part B prescription drugs provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis rendered on March 30, 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 services are not covered. 
 
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 lumbar-sacral orthosis 
rendered on March 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on February 18, 
2020 and billed under code 36415. 
 
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 while a portion of this claim was paid, Medicare requires modifiers to be used to 
indicate that a service or procedure has been altered by some specific circumstance, or to provide more specific 
information regarding the procedure performed. Most modifiers apply to a specific group of codes and may 
only be reported with those specified codes. The Plan states procedure code 36415 is disallowed with modifier 
Q4. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a modifier if the 
service billed with the modifier indicates a distinct procedural service. The code billed must be eligible for 
modifiers to be used. In this case code 36415 cannot be billed with modifier Q4. 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 February 18, 2020 and billed under code 36415.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone and/or joint imaging; whole body (CPT Code 
78306). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the member is in a clinical trial and Original Medicare covers the routine costs. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. The costs in a clinical trial are 
covered by Original Medicare. The health plan contract states, "Original Medicare pays most of the cost of the 
covered services you receive as part of the study. After Medicare has paid its share of the cost for these 
services, our plan will also pay for art of the costs. We will pay the difference between the cost-sharing in 
Original Medicare and your cost-sharing as a member of our plan. This means you will pay the same amount 
for the services you receive as part of the study as you would if you received these services from our plan." 
Therefore, we decided that the Plan does not have to pre-approve bone and/or joint imaging; whole body (CPT 
Code 78306).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a permanent pain pump implant. 
 
You asked the Plan to pre-approve a permanent pain pump implant. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says the enrollee already has an implanted 
spinal cord stimulator, therefore the pain pump is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that an implanted pain pump is contraindicated for 
enrollees with other implanted programmable devices and is not covered under such a circumstance. 
 
We looked at the file and Medicare rules. The enrollee already has an implanted programmable device; 
therefore, implantation of a pain infusion pump is contraindicated at this time. Based on this information, we 
decided that Medicare rules for coverage of a permanent pain pump implant have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a permanent pain pump implant.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy criteria have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that the 
criteria for coverage of Prolia have not been met. Our physician reviewer found the Plan requires a trial of 
Zoledronic acid before they will approve the requested drug. In this case, the patient has not tried and failed the 
required drug. There is no documentation provided indicating that the Plan's required drug is likely to be less 
effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the 
chest you had on June 17, 2020. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you were told that this test is free. 
The Plan denied your request. The Plan says you were charged the appropriate copayment for a CT scan. 
 
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 $225 
copayment for CT scans.  
 
You have been asked to pay the total allowable amount of $135.37 for the CT scan because it is less than your 
$225 copayment obligation. 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. Please note that low-dose CT scans for lung cancer screening is coverable yearly with no copayment.  
However, the records do not indicate this is what you received.  Screening low-dose CT scans are coded with 
procedure code G0297.  The CT scan you had was not a low-dose scan, and it was coded with procedure code 
71260.  Furthermore, your doctor indicated that the CT scan you had was performed as part of a workup for a 
solitary pulmonary nodule, not for screening for lung cancer. That is why you were charged this copayment 
correctly. Therefore, we decided that the Plan does not have to waive the copayment for the computed 
tomography (CT) scan of the chest you had on June 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring 
(95941) provided on October 24, 2019. 
 
You asked the Plan to pay for the continuous intraoperative neurophysiology monitoring. You say that you 
would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT 
code 95941 has a status indicator of I which is not valid for Medicare purposes. 
 
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 95941 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code 95941 has a status indicator of I. This means that CPT code 95941 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the continuous intraoperative 
neurophysiology monitoring have not been met. Therefore, we decided that the Plan does not have to pay for 
continuous intraoperative neurophysiology monitoring (95941) provided on October 24, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided April 12, 2020, to April 17, 
2020.  
 
You asked the Plan to pay for this claim. You say that this service should be covered by the Plan. The Plan 
denied your request. The Plan says his claim is being upheld because it is an exact duplicate of previously 
processed claims.  There were no codes billed to show this service was either a repeat or separately identifiable 
service.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the claim submitted is a duplicate to 
previously billed services. There is no indication this was a separate service from those previously billed.  
Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have 
to pay for physician services provided to the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for enteral supplies provided to the enrollee from November 10, 
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 Healthcare Common Procedure Coding System (HCPCS) code B4036 (30 Units) remains 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  is "Enteral feeding supply kit; gravity fed, per day, 
includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape." 
 
We find that HCPCS code  is not supported in the medical record. Specifically, there is no evidence of a valid 
physician order for these 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 enteral supplies 
provided to the enrollee from November 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychiatric diagnostic evaluation, neurobehavioral 
status exams, neuropsychological testing evaluation services, and psychological or neuropsychological test 
administrations to be provided by an OON provider. 
 
You asked the Plan to pre-approve the psychiatric diagnostic evaluation, neurobehavioral status exams, 
neuropsychological testing evaluation services, and psychological or neuropsychological test administrations. 
You say that you were referred to this provider by your OON stroke neurologist. You also say that this provider 
is a key medical specialist. The Plan denied your request. The Plan says these services are not emergent. The 
Plan also says that you can safely be treated by an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
psychiatric diagnostic evaluation, neurobehavioral status exams, neuropsychological testing evaluation 
services, and psychological or neuropsychological test administrations to be provided by an OON provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasound procedure you had at 
an outpatient hospital facility on January 27, 2020. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you had to have a second 
procedure because something was found during your mammogram.  You said that you didn't order this 
ultrasound, so you shouldn't have to pay for it. 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 $100 
copayment for diagnostic procedures and tests performed in an outpatient hospital facility.  
 
You have been asked to pay a $100 copayment for the ultrasound. The ultrasound falls within the diagnostic 
procedures and tests performed in an outpatient hospital facility benefit category. This copayment applies 
regardless of who ordered the test. 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 breast ultrasound 
procedure you had at an outpatient hospital facility on January 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says your care is not 
complex, and you do not need a team of providers. 
 
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 physician reviewer found 
that you were admitted to the acute hospital for pneumonia and an exacerbation of COPD. Your medical 
problems are stable. The complexity of your nursing, medical and rehabilitation needs do not require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You not require treatment by 
multiple therapies in an intensive rehabilitation therapy program. While the medical record does document a 
need for physical and occupational therapy, it does not document a need for an intensive rehabilitation 
program. 
 
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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup, including any pins when required 
(D2950) for tooth #31. 
 
You asked the Plan to pre-approve the core buildup. The Plan denied your request. The Plan says the crown 
does not require a core buildup. 
 
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 the core 
buildup when the services are medically necessary and reasonable.  
 
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 core buildup. Our reviewer says that 
the core buildup is not medically necessary. Our physician reviewer found the documentation provided does 
not substantiate the need for a core buildup (D2950) for tooth #31. Our reviewer also found that a radiograph 
with the old crown removed would be required. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the core buildup have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a core buildup, including any pins when required (D2950) for tooth #31.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office outpatient visit (99204) to be provided by an 
out of network (OON) provider. 
 
You asked the Plan to pre-approve office visit. You say that the services are medically necessary. The Plan 
denied your request. The Plan says there are qualified providers in-network that 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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the office outpatient visit (99204) to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous stabilization device. 
 
You asked the Plan to pre-approve the requested services. You say that the device would provide significant 
clinical and quality of life benefits. The Plan denied your request. The Plan says it is not identified as widely 
used and generally accepted for the proposed use. 
 
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 requested services. Our physician 
reviewer found that the requested device is considered experimental. More research is needed to show its safety 
and efficacy. Therefore, the requested service is not medically reasonable or 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an interspinous stabilization device.