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

We decided that the Plan does not have to pre-approve ablation of malignant prostate tissue with high-intensity focused ultrasound (HIFU).

You asked the Plan to pre-approve ablation of malignant prostate tissue with HIFU. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that whole gland HIFU is considered medically necessary as a local treatment for recurrent PCa following radiation therapy (RT) when specific criteria are met.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve ablation of malignant prostate tissue with HIFU. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee does not meet the coverage criteria detailed in the LCD. The records do not show that the enrollee has recurrent prostate following radiation treatment, as required by the LCD.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ablation of malignant prostate tissue with HIFU have not been met. Therefore, we decided that the Plan does not have to pre-approve ablation of malignant prostate tissue with high-intensity focused ultrasound (HIFU).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ongoing inpatient hospital care.

You asked the Plan to pre-approve inpatient care. You say that the requested services are medically necessary for the enrollee. The Plan denied your request. The Plan says the requested services are 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 inpatient care. Our reviewer says that the requested ongoing inpatient care is not considered medically reasonable and necessary in this case. Our physician reviewer found the provided documentation indicates that the enrollee's condition was stable as of September 1, 2022. Therefore, the reviewer found that ongoing inpatient care is not medically reasonable or 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 inpatient care have not been met. Therefore, we decided that the Plan does not have to pre-approve ongoing inpatient hospital care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic test provided on May 
3, 2022. 
 
You asked the Plan to waive the copayment for outpatient diagnostic test. You say that you feel they should 
waive the x-ray copayment as where no cost shares apply to you no matter where you go. The Plan denied your 
request. The Plan says this cost sharing was charged 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 $10 
copayment for Medicare-covered x-rays.  
 
You have been asked to pay $10 copayment for outpatient diagnostic test. This item/service falls within the 
Medicare-covered x-rays 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 
diagnostic test provided on May 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upright walker (E1399). 
 
You asked the Plan to pre-approve an upright walker. You say that the enrollee has Parkinsons, and she cannot 
use the regular walker because her hands shake a lot, and she falls. You also say if the enrollee cannot have her 
upright walker, she cannot have her knee surgery because she does not want her to fall. The Plan denied your 
request. The Plan says the enrollee was approved for a standard walker. The Plan also says records do not show 
that a standard walker will not meet her needs. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee was approved for a standard walker. The records submitted do not show that a 
standard walker will not meet the enrollees needs. A standard walker serves the same purpose as an upright 
walker. Therefore, we decided that the Plan does not have to pre-approve an upright walker (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a sleep study provided on June 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a sleep study. You say that this person needed this service. The Plan denied your 
request. The Plan says there was no preauthorization by a primary care provider (this is different than a 
referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, the 
decision is upheld. 
 
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 had network providers 
available who could have provided 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 a sleep study provided on June 14, 2022, 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 spacer procedure.

You asked the Plan to pre-approve an interspinous spacer procedure. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an interspinous spacer procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found interspinous spacers are experimental. More research is needed.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an interspinous spacer procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer procedure.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient diagnostic test and therapeutic 
services and supplies provided on March 22, 2022 
 
You asked the Plan to waive the coinsurance for medical supply. You say that you are appealing cost share 
charges. The Plan denied your request. The Plan says this cost sharing was charged 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 20% 
coinsurance for Medicare-covered medical supply. The allowed amounts of these medical supplies total $450, 
resulting in a total coinsurance amount $90.00. 
 
You have been asked to pay 20% coinsurance for medical supply. This item/service falls within the Medicare-
covered medical supply 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 outpatient 
diagnostic test and therapeutic services and supplies provided on March 22, 2022
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found continued care in the short-term acute care hospital is appropriate until you are stable 
to transfer to a lower 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for rehabilitation services provided from 
January 5, 2021, to February 2, 2022. 
 
You asked the Plan to waive the copayment for rehabilitation services. You say that these services are the only 
thing that somewhat help your diagnosis. However, the out of pocket (copayments, deductibles, etc) are too 
costly for you to actually receive the treatments at all. The Plan denied your request. The Plan says this cost 
sharing was charged 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 $20 
copayment for outpatient rehabilitation services. $20 x 2 visits = a $40 total. 
 
You have been asked to pay a $40 total copayment for rehabilitation services. This item/service falls within the 
outpatient rehabilitation 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 
rehabilitation services provided from January 5, 2021, to February 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the durable medical equipment (DME) 
provided on June 15, 2022. 
 
You asked the Plan to waive the coinsurance for the DME. You say that you were never told about a 
coinsurance for the equipment. The Plan denied your request. The Plan says this cost sharing was charged 
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 20% 
coinsurance for Medicare-covered durable medical equipment. The first total amount allowed was $7.12 with a 
coinsurance of $1.42 ($7.12 total amount allowed x 20% coinsurance). The second allowed amount was $14.82 
with a coinsurance of $2.96 ($14.82 total allowed amount x 20% coinsurance). The third allowed amount was 
$117.93 with a coinsurance amount of $23.59 ($117.93 total amount x 20% coinsurance). The fourth allowed 
amount was $14.83 with a coinsurance amount of $2.97 ($14.83 total allowed amount x 20% coinsurance). The 
fifth allowed amount was $21.48 with a coinsurance amount of $4.30 ($21.48 total amount x 20% coinsurance) 
The sixth allowed amount was $104.84 with a coinsurance amount of $20.97 ($104.84 total amount x 20% 
coinsurance). The total coinsurance amount was $56.21 ($1.42 coinsurance + $2.96 coinsurance + $23.59 
coinsurance + $2.97 coinsurance + $4.30 coinsurance + $20.97 coinsurance). 
 
You have been asked to pay a $56.21 coinsurance for the DME. This item/service falls within the Medicare-
covered durable medical equipment 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 durable medical equipment (DME) provided on June 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous passive motion (CPM) exercise device for 
use on knee only (E0935). 
 
You asked the Plan to pre-approve a CPM device. You say that you ordered a CPM machine, but the doctor did 
not put in an authorization for the device 48 hours prior to your surgery. You need the CPM machine to heal 
properly from your knee surgery. The Plan denied your request. The Plan says this device may be covered for 
patients who have a total knee replacement. Use of the device must start within two days of surgery. The device 
is covered for a three-week period following surgery. The Plan also says that records sent for review do not 
show that you meet these requirements. 
 
The Plan must follow Medicare rules. The rules say that CPM devices are covered only if use of the device 
began within two days of receiving total knee replacement surgery.  
 
Records show that total knee replacement surgery was received on September 6, 2022, and the CPM was 
ordered on September 22, 2022, sixteen days after the knee surgery. Use of a CPM device has not yet begun. 
This means that use of a CPM device was not started until more than two days had elapsed following total knee 
replacement surgery. Therefore, we decided that the Plan does not have to pre-approve a continuous passive 
motion (CPM) exercise device for use on knee only (E0935).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) provided on April 20, 2022.

You asked the Plan to pay for the evaluation and management service. You say that the enrollee's symptoms were sudden. You also say that the service was medically necessary. The Plan denied your request. The Plan says the service was not urgent or emergent in nature.

Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.  

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the evaluation and management service. Our reviewer says that the out of area office visit was not medically necessary. Our physician reviewer found the provided documentation does not indicate that the services the enrollee received out of network were urgent or emergent. Therefore, the reviewer found that the out of area office visit was not medically necessary in this case.

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 evaluation and management service have not been met. Therefore, we decided that the Plan does not have to pay for the office visit (99214) provided on April 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided on July 9, 2021 to July 11, 2021, at the Diagnosis Related Group (DRG) originally billed.

You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you disagree with the denial. The Plan denied your request. The Plan says the submitted records do not support the billing of diagnosis code I21.A1

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.  

In this case, you billed the inpatient services provided with diagnosis code I21.A1. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says that the submitted records do not support the billing of diagnosis code I21.A1. Our physician reviewer found the enrollee presented to the hospital with chest pain, syncope, and a rapid heart rate. He was found to be in atrial fibrillation and was initiated on a Cardiozem drip, later transitioning to an Amiodarone drip. While the physician indicated a diagnosis of "Type II MI (myocardial infarction)," the clinical evidence in the medical record did not support the diagnosis. The elevation in troponin alone does not validate the diagnosis of acute myocardial infarction. In addition, per Cardiology, the electrocardiogram (EKG) was unchanged from baseline. The records do not support the billing of diagnosis I21.A1. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided on July 9, 2021 to July 11, 2021, at the Diagnosis Related Group (DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service May 26, 2022.

You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. The Plan denied your request. The Plan says code 83789 is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine specimens utilized for drug testing should not separately bill the validity testing.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service May 26, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483) provided on October 28, 2021.

You asked the Plan to pay for the lab services. You say that this claim was billed correctly. The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim.

The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the Plan does not have to pay for lab services (G0483) provided on October 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided from December 28, 2021, to December 31, 2021.

You asked the Plan to pay for laboratory services. You say that these services were necessary. The Plan denied your request. The Plan says insufficient information was provided to process this claim.

The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.


We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of laboratory services have been met. Specifically, no documentation was submitted to support that these services were medically necessary and ordered by the enrollee's treating physician and no documentation was provided to support that these services were reported accurately. Therefore, we decided that the Plan does not have to pay for laboratory services provided from December 28, 2021, to December 31, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code G0482 billed for date of service March 2, 2022.

You asked the Plan to pay for procedure code G0482. You say that this service is supported as billed. The Plan denied your request. The Plan says payment for code G0482 is included in the payment for G0483.

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, we have confirmed that code G0482 is a column II code to column I code G0483 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code G0482 billed for date of service March 2, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service May 11, 2022.

You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. The Plan denied your request. The Plan says code 83789 is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine specimens utilized for drug testing should not separately bill the validity testing.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service May 11, 2022.