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

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service April 11, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says code 99153 is not payable in the facility 
setting. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service April 11, 2022, billed 
with code 99153.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT) scans of the chest and of the 
abdomen/pelvis. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has a prostate specific antigen 
(PSA) of 6.07. His prostate biopsy showed 3+4 left lateral apex. He tested negative for a genetic mutation. He 
is considered favorable, and intermediate for metastatic risk. The National Comprehensive Cancer Network 
(NCCN) guidelines indicate that a CT of the abdomen and pelvis is a reasonable staging procedure and is 
medically necessary at this time. The chest CT is reasonable and medically necessary due to the enrollee's 
family history of lung cancer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve computed tomography (CT) scans of the chest and of the abdomen/pelvis.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76775 billed for date of service August 4, 
2022. 
 You asked the Plan to pay for procedure code 76775. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 76775 is bundled into payment for 
code 93976. 
 
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 76775 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 76775 billed for date of service August 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) (E0652) and 
appliance (E0667). 
 
You asked the Plan to pre-approve the PCD and appliance. The Plan denied your request. The Plan says this is 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PCD coded as E0652 is not covered for the 
treatment of lymphedema of the extremities alone even if the criteria in this section are met. Claims will be 
denied as not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the PCD and appliance. Our reviewer 
says that the requested PCD is not medically reasonable and necessary. Our physician reviewer found that the 
provided physical examination notes in the medical records do not document edema anywhere other than the 
lower extremities. Although the provided letter of medical necessity and the device prescription report lymphedema extending onto the trunk, the provided physical examination notes do not support this finding. 
 
We looked at this physician's review, the file, and Medicare rules. As the requested PCD is not covered in this 
case, the appliance (E0667) is also not covered. Based on this information, we decided that Medicare rules for 
coverage of the PCD and appliance have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a pneumatic compression device (PCD) (E0652) and appliance (E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Energizer batteries. 
 
You asked the Plan to pre-approve Energizer batteries. You say that you do not have enough money to buy 
them for your insulin pump. The Plan denied your request. The Plan says the requested items are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve Energizer batteries.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and x-ray provided on November 30, 2021, by 
an OON provider. 
 
You asked the Plan to pay for the office visit and x-ray. The Plan denied your request. The Plan says the out-of-
network services were not authorized. 
 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 an office visit and x-ray provided on November 
30, 2021, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 24, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 laboratory services provided on May 24, 2022, by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 15275 billed for date of service April 14, 
2022. 
 
You asked the Plan to pay for procedure code 15275. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 15275 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 15275 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 15275 billed for date of service April 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dermatology services provided on July 11, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for dermatology services. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 dermatology services provided on July 11, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical consultation to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the surgical consultation. You say that you need to surgery to be done by the 
OON provider because they are closer to family. The Plan denied your request. The Plan says the requested 
provider is an OON provider and there are multiple in-network providers that are available to render the needed 
services to the enrollee. 
 
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 
a surgical consultation to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided to the enrollee from July 4, 2020, to July 
14, 2020. 
 
You asked the Plan to pay for the services. You say that this is an erroneous denial. The Plan denied your 
request. The Plan says that the physical therapy visit dated July 6, 2020, was labeled as a 30-day re-evaluation, 
but did not contain all of the components of a valid reassessment. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has allowed that the reassessment from July 4, 2020, was valid. They 
are taking issue with the reassessment on July 6, 2020, not being valid. However, the plan's denial is not 
substantiated as the "clock" for 30-day functional reassessment would have reset due to the valid reassessment 
from July 4, 2020. The visit on July 6, 2020, would not be required to be a fully valid reassessment, with 
successive comparison or the therapist's determination of the effectiveness of therapy or lack thereof, as it was 
less than 30 days from the valid reassessment on July 4, 2020. The plan has not applied these rules correctly. 
Therefore, we decided that the Plan has to pay for home health services provided to the enrollee from July 4, 
2020, to July 14, 2020.  
 
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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an oral appliance. 
 
You asked the Plan to pre-approve an oral appliance. You say that you feel you need this appliance for sleep 
apnea. The Plan denied your request. The Plan says that the requested device is not medically necessary. 
The Plan follows Medicare rules. Medicare rules say that oral appliances are covered for certain indications. 
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 oral appliance. Our reviewer says 
that the documentation supports that the requested oral appliance is medically reasonable and necessary. Our 
physician reviewer found you have sleep apnea and cannot wear a continuous positive airway pressure (CPAP) 
or bilevel positive airway pressure (BiPap) because you have claustrophobia and when you have worn it you 
end up taking the mask off while you are sleeping. The documentation indicates that you meet A-D of the 
above LCD criteria. Therefore, you meet criteria for the requested oral appliance. 
 
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 oral appliance have been met. Therefore, we decided that the Plan has to pre-
approve an oral appliance.  
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 6, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you would like to appeal and have the claim 
reprocessed as a contracted provider. The Plan denied your request. The Plan says the rendering provider was 
an OON provider during the date of service and the service rendered was not urgent or emergent. 
 
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 an office visit provided on December 6, 2021, by 
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dual-energy x-ray provided on July 12, 2022, by an OON 
provider. 
 
You asked the Plan to pay for the dual-energy x-ray. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the out-of-network services were not authorized. 
 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 dual-energy x-ray provided on July 12, 2022, by 
an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the semi-electric hospital bed (CPT code E0260). 
 
You asked the Plan to pre-approve the semi-electric hospital bed. You say that you need the bed due to having 
many clinical issues and you feel the service is medically necessary. The Plan denied your request. The Plan 
says this bed is denied due to lack of need for frequent or immediate changes in body position. 
 
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 semi-electric hospital bed. Our 
physician reviewer found you do not require positioning of the body in ways not feasible with an ordinary bed. 
You do not require attachments that cannot be fixed and used on an ordinary bed. The head of the bed does not need to be elevated over 30 degrees most of the time. The documentation does not reveal a frequent or 
immediate need for a change in body position therefore this request is not medically necessary. You have 
normal ejection fractures, no shortness of breath, orthopnea or PND. You have no fluid overload, and your 
pulse ox is 97 percent on room air. LCD: Hospital Beds And Accessories (L33820) coverage criteria has not 
been met; therefore, this request is not medically 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 the semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the semi-electric hospital bed (CPT code E0260).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intra-fraction localization and tracking of target or patient 
motion during delivery of radiation therapy provided on May 6, 2022. 
 
You asked the Plan to pay for intra-fraction localization and tracking of target or patient motion during delivery 
of radiation therapy. You say that the services were medically necessary. The Plan denied your request. The 
Plan says the provider is an out of network provider. The services provided were not emergency care. There 
was ample time to request prior authorization before providing this service. There was time to verify insurance 
prior to providing the radiation treatment. There is no prior authorization or a referral from an in-network 
provider on file. It is the responsibility of the provider and the member to verify benefits and coverage prior to 
rendering or receiving services. 
 The contract with the Plan says for certain services, you or your provider will need to get approval from the 
Plan before we can cover the service. If you do not get this approval, your service might not be covered by the 
Plan. 
 
We looked at the file and the Plans rules. 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 intra-fraction localization 
and tracking of target or patient motion during delivery of radiation therapy provided on May 6, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan (93971) provided on April 11, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the duplex scan. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this service was performed by an out-of-network provider and referred by 
an out-of-network provider. Out-of-network care is only covered in certain limited circumstances. 
 
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 duplex scan (93971) provided on April 11, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasonic guidance for radiation treatment. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the use of ultrasound on a daily basis 
for radiation therapy is not the standard of care for your condition. The services are not reasonable or medically 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ultrasonic guidance for radiation treatment.