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

 
We decided that the Plan does not have to waive the deductible for the magnetic resonance imaging (MRI) of 
the lumbar spine (72148) provided on December 14, 2021. 
 
You asked the Plan to waive the deductible. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the deductible has been applied correctly to 
the service provided. 
 
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 the yearly deductible is 
$750. This is the amount you have to pay out-of-pocket before the Plan will pay their share for your covered 
medical services. Until you have paid the deductible amount, you must pay the full cost of your covered 
services.   
You have been asked to pay $257.70 for the outpatient radiological diagnostic service provided as you had not 
previously met the yearly deductible. This is the Plans allowed amount for this service. 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 deductible for the magnetic resonance imaging (MRI) of the lumbar spine (72148) 
provided on December 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left sided facet joint injections at the C4-C5 level. 
 
You asked the Plan to pre-approve the facet joint injections. You say that it is felt that this treatment is 
medically indicated. The Plan denied your request. The Plan says there was no complete physical examination 
of the neck pain to support facet joint involvement. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections may be considered medically 
necessary when the criteria listed in the Medicare rules section of this decision 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 the facet joint injections. Our reviewer 
says that the requested cervical facet joint injections are not shown to be medically necessary. Our physician reviewer found the enrollee is a female with neck and back pain. The notes indicate a history of a right sided 
stroke. There is no documentation of quantified decreased range of motion, motor, sensory or reflexes. The 
request does not meet the minimum required documentation of a physical exam.  The request, at this point, 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 the facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve left sided facet joint injections at the C4-C5 level.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower extremity magnetic resonance angiography 
(MRA). 
 
You asked the Plan to pre-approve an MRA. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that MRA of peripheral arteries is useful in determining 
the presence and extent of peripheral vascular disease in lower extremities. 
 
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 MRA. Our reviewer says that the 
requested MRA is not medically necessary. Our physician reviewer found a venous duplex was performed and 
did not reveal deep venous thrombosis. The reviewer found that the records provided do not document a 
vascular examination or the results of an arterial duplex examination. Therefore, the reviewer found that the 
records provided do not support the medical necessity of the requested service. 
 
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 MRA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a lower extremity magnetic resonance angiography (MRA).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on December 
16, 2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the CT scan. You say that it was medically necessary to provide the service to 
the enrollee. The Plan denied your request. The Plan says the rendering provider is an OON provider and there 
was no referral from an in-network provider or an approved authorization. Also, 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 the computed tomography (CT) scan provided on 
December 16, 2020, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 10, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service March 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70480 billed for date of service March 3, 
2022. 
 You asked the Plan to pay for procedure code 70480. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70480 is bundled into payment for 
code 70450. 
 
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 70480 
is a column II code to column I code 70450. 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 70480 billed for date of service March 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided by a participating 
provider on March 2, 2022. 
 
You asked the Plan to pay for periodontal maintenance. You say that you would like the Plan to pay for this. 
The Plan denied your request. The Plan says the rendered dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 
periodontal maintenance (D4910) provided by a participating provider on March 2, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy services (97110, 97530, 
97112) provided from January 4, 2022, to January 11, 2022. 
 
You asked the Plan to waive the copayment for the physical therapy services. You say that the services should 
be covered as you disagree with the denial. The Plan denied your request. The Plan says the cost-sharing 
applied correctly based on the services provided. 
 
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 10% 
coinsurance for Outpatient Rehabilitation Services.  
 
 
  You have been asked to pay a 10% coinsurance for physical therapy services (allowed is $332.34 x 10% = 
$33.08). Physical therapy services fall 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 physical therapy services (97110, 97530, 97112) provided 
from January 4, 2022, to January 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthodontic retention (removal of appliances, 
construction and placement of retainer(s)) (D8680) provided February 3, 2022. 
 
You asked the Plan to pay for the orthodontic retention. You say that you were told in mid-February that the 
retainer would be covered at 50%. The Plan denied your request. The Plan says this service is not covered 
under your benefits. The Plan also says they were unable to find any authorization or customer calls on file for 
this service prior to the services being provided. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 
orthodontic retention (removal of appliances, construction and placement of retainer(s)) (D8680) provided 
February 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on February 20, 
2022 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the denial is not valid due to the fact 
you were admitted to hospital for sepsis infection. You say that you were not admitted due to lifting something 
heavy. You also say that you were not stable at the time of the admission. The Plan denied your request. The 
Plan says the inpatient admission was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on February 20, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99348) provided on January 12, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is included in the 
global surgery payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who performs the surgery. 
 
We looked at the file and Medicare rules. Payment for the requested service is included in the global surgical 
payment for the procedure (11721) provided on the same date of service. 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 the services (99348) provided on January 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit for a diagnostic eye 
examination performed by an in-network provider on January 15, 2021. 
 
You asked the Plan to waive the copayment for a vision exam. You say that you went to the physician's office 
for a routine eye exam and do not think you should be responsible for the copayment. The Plan denied your 
request. The Plan says the cost-share was processed correctly according to the Plan's benefits for vision care. 
The Plan contacted the billing provider and confirmed that you did not present to the office for a routine eye 
exam. The Plan says the submitted medical record indicates you presented to the office for a follow-up visit 
regarding a previously identified medical condition. 
 
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 $30 
copayment for Vision Care.  
 
 
 You have been asked to pay a $30 copayment for a vision exam. The service at issue falls within the Vision 
Care benefit category. You received vision care from an in-network provider to treat an eye condition. 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 office visit for a diagnostic eye examination performed 
by an in-network provider on January 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection on January 4, 2022. 
 
You asked the Plan to waive the copayment for an injection. You say that you would like to appeal the cost 
share. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $50 
copayment for an injection.  
 
You have been asked to pay a $50 copayment for an injection. An injection falls 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 copayment for an injection on 
January 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 10, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided on November 10, 2021, by 
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an MRI provided on February 11, 2022, 
and February 15, 2022. 
 
You asked the Plan to waive the copayments for an MRI. You say that you think your copayments should be 
waived. The Plan denied your request. The Plan says you pay a $100 per day for Medicare-covered diagnostic 
radiology services. An MRI would fall under this category. 
 
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 per day for Medicare-covered diagnostic radiology services.  
 
You have been asked to pay $200 for two MRIs ($100 x 2). An MRI 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 copayments 
for an MRI provided on February 11, 2022, and February 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT), abdomen and pelvis; with 
contrast material(s) (74177). 
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. You say that the CT scan is necessary 
to find the source of your medical problem. The Plan denied your request. The Plan says the medical records do 
not show results of a prior ultrasound that failed to find the source of your problem. 
 
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 a CT scan of the abdomen and pelvis. 
Our reviewer says that a CT scan of the abdomen and pelvis is not medically reasonable and necessary. Our 
physician reviewer found that a CT scan as requested is premature, and therefore neither medically appropriate 
nor necessary at this point in your evaluation. Standard-of-care initial evaluation of right upper quadrant pain in 
your setting includes pertinent lab studies and ultrasound. Your records do not support concern for pelvic 
pathology to warrant the pelvic imaging as ordered. Radiation exposure by abdominal CT scan, without prior 
abnormalities seen on abdominal ultrasound nor in evaluation of abnormal liver testing, is unwarranted. 
 
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 CT scan of the abdomen and pelvis have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT), abdomen and pelvis; with contrast 
material(s) (74177).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacing an old implantable loop recorder (ILR) with a 
new ILR. 
 
You asked the Plan to pre-approve the replacement of an ILR. You say that the records provided support the 
need for the requested device. The Plan denied your request. The Plan says they did not receive notes 
explaining why the enrollee would need additional long-term heart monitoring with a new loop recorder. 
 
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 replacement of an ILR. Our 
reviewer says that the replacement of an ILR is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the ILR had been placed to search for silent atrial fibrillation, which has never 
been observed over the life of the device. As such, based on current guidelines and the documentation 
provided, there is insufficient clinical evidence to support the medical appropriateness and necessity of 
replacing the enrollee's old ILR with a new ILR. 
 
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 replacement of an ILR have not been met. Therefore, we decided that the 
Plan does not have to pre-approve replacing an old implantable loop recorder (ILR) with a new ILR.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zelnorm tablet. 
 
You asked the Plan to pre-approve Zelnorm. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested drug is considered self-administered. The 
Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also 
says the requested drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Zelnorm tablet.  
 Benefits for Zelnorm may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.