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

 
We decided that the Plan does not have to waive the copayment for Ultrasound on February 28, 2022. 
 
You asked the Plan to waive the copayment for ultrasound. You say that you already paid the copayment. The 
Plan denied your request. The Plan says the cost-sharing you are being charged 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 $150 
copayment for Medicare-covered radiological diagnostic services, not including X-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic). Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies. Covered services include, but are not limited to: Other 
outpatient diagnostic tests -Radiological diagnostic services, not including x-rays. The provider billed in the 
amount of $340.00 and the allowed amount is $76.62. This is less than the copayment amount. Therefore, 
results in the total cost-sharing amount of $76.62. 
 You have been asked to pay the allowed amount of $76.62, which is less then the $150 copayment for 
ultrasound. Ultrasound 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 Ultrasound on February 28, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 1, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says payment for code 76705 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 76705 
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 76705 billed for date of service March 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 12, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this 
information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing provided on May 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PureWick external female catheter. 
 
You asked the Plan to pre-approve a PureWick external female catheter. You say that the requested item is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested item is not a 
covered benefit. 
 
The Plan follows Medicare rules. Medicare rules say that incontinence supplies are not covered because they 
are hygienic items that are non-reusable. 
 
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 PureWick external female catheter. 
Our reviewer says that the requested item is not medically reasonable and necessary. Our physician reviewer 
found that Medicare does not cover incontinence supplies because they are disposable, non-reusable hygiene 
items and fall outside the scope of coverage.  
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 PureWick external female catheter have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a PureWick external female catheter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chemodenervation (64616) and needle electromyography 
(95874) provided on January 19, 2022. 
 
You asked the Plan to pay for chemodenervation (64616) and needle electromyography (95874). The Plan 
denied your request. The Plan says procedure code 64616 exceeded the number of allowable units and 
procedure code 95874 was billed without an eligible primary procedure code. 
 
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 64616 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 
chemodenervation (64616) have not been met. In addition, we have confirmed that code 95874 is an add-on 
code. CPT code 95874 has been billed with an appropriate primary procedure code; however, the primary 
procedure code is not eligible for payment for exceeding the billable units. Based on the claim submitted, 
Medicare billing criteria for needle electromyography (95874) have not been met. Therefore, we decided that 
the Plan does not have to pay for chemodenervation (64616) and needle electromyography (95874) provided on 
January 19, 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 services requested are medically 
necessary. The Plan denied your request. The Plan says the services requested are 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 are no services at the LTACH that the patient requires that are not already 
available and covered at the current facility. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 9, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
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 rendered on December 9, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve MyOwn skin (Q4226) and application of skin substitute graft 
(15271). 
 
You asked the Plan to pre-approve MyOwn skin and application of skin substitute graft. You say that the 
requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says that the 
requested services are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 MyOwn skin and application of skin 
substitute graft. Our reviewer says that the requested services are considered medically reasonable and 
necessary in this case. Our physician reviewer found the requested services meet criteria for approval because 
all other trialed approaches have failed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MyOwn skin and application of skin substitute graft have been met. Therefore, 
we decided that the Plan has to pre-approve MyOwn skin (Q4226) and application of skin substitute graft 
(15271).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation services provided on January 25, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for observation services. You say that you cannot afford this bill. The Plan denied 
your request. The Plan says prior authorization was not obtained. 
 
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 observation services provided on January 25, 
2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and 
services. 
 
You asked the Plan to pay for IRF care. You say that you want to be admitted to this IRF facility. The Plan 
denied your request. The Plan says this does not meet Medicare criteria. 
 
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 pay for 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 the patient's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician reviewer also found that the patient's medical status does not require intensive physician and nursing oversight 
in an IRF. 
 
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 pay for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a power operated vehicle. 
 
You asked the Plan to pre-approve a power operated vehicle. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says that the requested item is not a covered 
benefit. 
 
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 states that the requested item is not a covered benefit. The 
documentation provided by the Plan does not include Medicare rules used to support their decision. The Plan 
also states that the Evidence of Coverage (EOC) states that this item is not covered. The EOC states that 
covered items include wheelchairs. The Plan has not substantiated their denial. Therefore, we decided that the 
Plan has to pre-approve a power operated vehicle.  
 
Also, note that 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 at issue in this appeal. 
 
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 pre-approve a Synvisc injection. 
 
You asked the Plan to pre-approve a Synvisc injection. 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 Hyaluronans Intra-articular Injections are covered 
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 a Synvisc injection. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the enrollee has not had an 
adequate trial of conservative therapy. Therefore, at this time, the request is deemed 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 a Synvisc injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Synvisc injection.
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 enrollee currently meets full IRF criteria. The 
Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an 
IRF. 
 
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 the patient's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician 
reviewer also found that the patient's medical status does not require intensive physician and nursing oversight 
in an IRF. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (62321). 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for coverage of 
the requested service have not been met. 
 The Plan follows Medicare rules. The rules say that an epidural steroid injection is medically reasonable and 
necessary when the requirements listed in the Medicare rules section have been 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 an epidural steroid injection. Our 
reviewer says that the requested service is not medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee should have a magnetic resonance imaging (MRI) scan to delineate whether 
there is disc disease, facet disease or both. 
 
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 epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection (62321).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cala Trio stimulator device. 
 
You asked the Plan to pre-approve the Cala Trio stimulator device. You say that the device is medically 
necessary. The Plan denied your request. The Plan says this device is experimental. Coverage criteria is not 
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 the Cala Trio stimulator device. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found review of the current medical literature does not consider this service to be 
standard medical treatment for your condition. The efficacy of device is still uncertain at this time and it is not 
recommended in current guidelines for the treatment of essential tremor. 
 
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 Cala Trio stimulator device have not been met.  
 
 
  
 
Therefore, we decided that the Plan does not have to pre-approve a Cala Trio stimulator device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and chemotherapy services provided on 
February 9, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and chemotherapy services. You say that a mistake was made, 
and the enrollee's insurance was not checked. The Plan denied your request. The Plan says the services were 
provided out-of-network and were not approved in advance. 
 
 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 office visit and chemotherapy services 
provided on February 9, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on March 10, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 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 services provided on March 10, 2022 by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care (99291) provided on October 27, 2021. 
 
You asked the Plan to pay for critical care (99291). You say that the documentation supports CPT code 99291 
and should be reviewed for payment. The Plan denied your request. The Plan says the documentation submitted 
did not support a critical care visit of 30-74 minutes was performed. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
 
  We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not document 
the time spent on critical care services as required by the CPT code billed. Based on this information, we 
decided that Medicare rules for coverage of critical care (99291) have not been met. Therefore, we decided that 
the Plan does not have to pay for critical care (99291) provided on October 27, 2021.