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

 
We decided that the Plan does not have to pay for out of network chiropractic services provided from May 19, 
2021, to May 24, 2021 . 
 
You asked the Plan to pay for out of network services. You say that these services should be covered by the 
Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care. 
 
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 Plan contract also states chiropractic care may need prior 
authorization.  The 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 out of network chiropractic services provided from 
May 19, 2021, to May 24, 2021 .
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a radiofrequency ablation of lateral sacral branches 
(64625). 
 
You asked the Plan to pre-approve a radiofrequency ablation of lateral sacral branches. You say that the 
requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says 
medical necessity rules for the requested procedure 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 a radiofrequency ablation of lateral 
sacral branches. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the requested procedure is considered experimental 
due to the wide variation in efficacy reported in the literature. 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 radiofrequency ablation of lateral sacral branches have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a radiofrequency ablation of lateral sacral 
branches (64625).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care services provided on July 7, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the wound care services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 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 the wound care services provided on July 7, 2021 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a suture of a muscle rupture (27385) and a revision of a total 
knee arthroplasty (27486) provided on October 6, 2020. 
 
You asked the Plan to pay for a suture of a muscle rupture and a revision of a total knee arthroplasty. You say 
that these codes are supported in the records. The Plan denied your request. The Plan says these procedures are 
not documented. 
 
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 27385 is suture of quadriceps or hamstring muscle 
rupture; primary. The definition of 27486 is revision of total knee arthroplasty, with or without allograft; 1 
component. 

 We asked our coder 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 a suture of a muscle rupture and a revision of a total knee 
arthroplasty. Our reviewer says that these codes are not supported. Our reviewer found the operative report 
does not document quadriceps or hamstring muscle sutures, therefore 27385 cannot be confirmed as performed. 
In regard to 27486, the operative report does not include enough detail to confirm a revision of total knee 
arthroplasty 1 compartment has been performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a suture of a muscle rupture and a revision of a total knee arthroplasty have not 
been met. Therefore, we decided that the Plan does not have to pay for a suture of a muscle rupture (27385) and 
a revision of a total knee arthroplasty (27486) provided on October 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound study provided on June 10, 
2021. 
 
You asked the Plan to waive the copayment for an ultrasound study. You say that you thought the Plan would 
pay the charges in full. 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 $155 
copayment for radiological diagnostic services.  
 
You have been asked to pay the allowed amount of $141.77, which is less than the $155 copayment for an 
ultrasound study. An ultrasound study falls within the outpatient diagnostic tests and therapeutic services and supplies 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 an ultrasound study 
provided on June 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal adjustment - limited (D9951) provided July 20, 
2021. 
 
You asked the Plan to pay for the occlusal adjustment. You say that the service was medically necessary due to 
a medication which affected your jaw. The Plan denied your request. The Plan says this service is not covered 
under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
occlusal adjustment - limited (D9951) provided July 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hot or cold packs therapy provided on July 1, 2021. 
 
You asked the Plan to pay for the hot or cold packs therapy. You say that authorization is not needed, and the 
claim should be reprocessed. The Plan denied your request. The Plan says codes 97110 and 97140 were 
approved for payment. The Plan also says that code 97010 remains denied as bundled services are not eligible 
for separate reimbursement. 
 
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 97010 is application of a modality to 1 or more areas; hot 
or cold packs.  
We find that CPT code 97010 is not supported in the medical record. Specifically, CPT code 97010 has a status 
indicator of B. This means that CPT code 97010 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the hot or cold packs therapy have not been 
met. Therefore, we decided that the Plan does not have to pay for the hot or cold packs therapy provided on 
July 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One (J7325). 
 
You asked the Plan to pre-approve Synvisc-One. You say that the Synvisc-One is medically necessary. The 
Plan denied your request. The Plan says the enrollee has not tried and failed the required drugs, Monovisc and 
Orthovisc. 
 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 Synvisc-One. Our reviewer says that 
Synvisc-One is not medically necessary. Our physician reviewer found the provided documentation indicates 
that the enrollee has not tried and failed both required drugs. The reviewer found that the documentation 
supports that the enrollee has tried and failed Monovisc, but not Orthovisc. The reviewer also found that there 
is no indication that the plan's required drug would likely be less effective and/or likely have adverse effects for 
the enrollee. Therefore, the reviewer found that the step therapy criteria has not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc-One have not been met. Specifically, the file shows that the enrollee 
has only tried and failed one of the required drugs. Therefore, we decided that the Plan does not have to pre-
approve Synvisc-One (J7325).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services (20931) provided December 21, 
2020. 
 
You asked the Plan to pay for the surgical assistant services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the service at issue is not eligible for surgical assistant 
payment. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 20931. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid.  Based upon this information, we find that Medicare coverage criteria for the surgical assistant services have not been met. Therefore, we decided that the Plan does not have to pay for surgical assistant services (20931) 
provided December 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the inpatient care provided from March 
24, 2020, to March 25, 2020. 
 
You asked the Plan to pay an additional amount for the inpatient care. You say that deep vein thrombosis 
(DVT) is always significant. You also say that you feel that chronic DVT was significant and impacted the care 
the enrollee received post-operatively. The Plan denied your request. The Plan says the billing of International 
Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) code I82.503, chronic embolism 
and thrombosis of unspecified deep veins of lower extremity, bilateral, is not supported. 
 
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 ICD-10-CM code I82.503, chronic embolism and 
thrombosis of unspecified deep veins of lower extremity, bilateral. 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 an additional amount for the inpatient care. Our physician reviewer found the 
provided documentation indicates that the enrollee's initial diagnosis was in 2017. The reviewer found that the 
enrollee's diagnosis has been controlled by medication since then. The reviewer found that further provider 
documentation states, "history of DVT (deep vein thrombosis) of lower extremity" and "Past Medical History 
of bilateral DVT, IVC (inferior vena cava) filter in place". The anesthesia provider documented in the 
preoperative assessment, "Anticoagulation: No. Therefore, the reviewer has determined that the provided 
records did not support the billing of ICD-10-CM code I82.503, chronic embolism and thrombosis of 
unspecified deep veins of lower extremity, bilateral.  
 
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 
an additional amount for the inpatient care provided from March 24, 2020, to March 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 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 there is no documentation provided necessitating admission to a LTACH. The 
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at 
the LTACH that are not available at the present setting where he is currently receiving care. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. 
 
 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 LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) provided on 
February 22, 2021. 
 
You asked the Plan to pay for the services provided. You say that the enrollee had 2 separate procedures. The 
Plan denied your request. The Plan says an appropriate modifier was not 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 code 70544 was billed with code 70552. The CPT code at issue, 70544, may be eligible for 
separate payment. However, the claim provided does not show that code 70544 was billed with a modifier 
suitable for payment. Based on this information, we decided that Medicare rules for coverage of the services 
provided have not been met. Therefore, we decided that the Plan does not have to pay for the magnetic 
resonance angiography (MRA) provided on February 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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 do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the documentation does support a need for physical and/or occupational 
therapy, there is no documented need for an intensive, multi-disciplinary 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breast ultrasound (76642), diagnostic mammography 
(77066), and the diagnostic digital breast tomosynthesis (G0279) rendered by the out-of-network (OON) 
provider on November 5, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. 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 the breast ultrasound (76642), diagnostic mammography (77066), and the 
diagnostic digital breast tomosynthesis (G0279) rendered by the out-of-network (OON) provider on  
November 5, 2020.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the contact lens fitting (92310). We decided that the Plan does not have 
to pay for the fundus photography (92250).  
 
You asked the Plan to pay for the contact lens fitting (92310) and the fundus photography (92250). You say 
that you would like the Plan to reconsider your request. The Plan says that the services are not covered. 
 
We decided that the Plan has to pay for the contact lens fitting (92310).  
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file and the Plan's contract. The Plan's contract clearly covers contact lens fittings under the 
supplemental vision benefit. Therefore, we decided that the Plan has to pay for the contact lens fitting (92310).  
 
We also decided that the Plan does not have to pay for the fundus photography (92250). 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file, the Plan's contract and Medicare rules. Medicare does not cover this service and the Plan 
does not offer coverage of this service under the Plan's supplemental vision benefit. Therefore, we decided that 
the Plan does not have to pay for the fundus photography (92250). 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 11, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results. 
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on June 11, 2021.