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

 
We decided that the Plan does not have to pre-approve upper extremity studies (93930 and 93931). 
 
You asked the Plan to pre-approve upper extremity studies. You say that you have had this service performed 
before at the same hospital setting. You also say that the redirected imaging center does not perform the 
procedures as indicated by the denial notice. The Plan denied your request. The Plan says the requested 
services were submitted incorrectly by the requesting provider office and should have been for the lower 
extremities. The Plan also says that the provider states ultrasound services do not need to be provided in the 
outpatient hospital setting but can be provided at the outpatient network radiology center. 
 
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 upper extremity studies. Our reviewer 
says that the requested upper extremity studies are not considered medically reasonable and necessary in this 
case. Our physician reviewer found you have bilateral lower extremity claudication and diminished pulses, and 
would benefit from a bilateral lower extremity duplex arterial ultrasound (code 93925). Our reviewer found 
that there is no need to perform this exam in a hospital imaging department if the same exam can be performed 
in an outpatient imaging center. Our physician reviewer also found the communication between the Plan and 
the referring clinician indicates the physician is aware of this denial, and amenable to resubmitting the proper 
referral including a different and accurate current procedural terminology code as well as a referral for said 
exam to an appropriate outpatient imaging center. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of upper extremity studies have not been met. Therefore, we decided that the Plan 
does not have to pre-approve upper extremity studies (93930 and 93931).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on October 
24, 2021. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that this copayment is too high 
and you cannot afford this charge. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for Ambulance services. 
 
You have been asked to pay a $325 copayment for ambulance transport. This item/service falls within the 
Ambulance 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 ambulance transport 
provided on October 24, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for a bone anchor/screw used in a surgical procedure 
provided on April 21, 2022. 
 
You asked the Plan to waive the coinsurance for the bone anchor/screw. You say that this charge is incorrect. 
The Plan denied your request. The Plan says that this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan does not say in clear and accurate terms 
how much you should expect to pay for surgical supplies/hardware.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a 20% 
coinsurance for surgical supplies/hardware. The Plan contract does not clearly say how much enrollees must 
pay for this item/service. This means that the Plan did not follow Medicare rules for disclosure of cost sharing 
information. Therefore, we decided that the Plan has to waive the coinsurance for a bone anchor/screw used in 
a surgical procedure provided on April 21, 2022.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
January 23, 2022, to February 21, 2022. 
 
You asked the Plan to pay for home health services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the claim must be completed 
for home health care services to be covered. 
 
 We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the 
enrollees claims history, the NOA claim with the artificial admission date was billed as January 23, 2022. 
Subsequent reporting of the admission/start of care date on the 30-day period of care claim for January 23, 
2022, through February 21, 2022, is reported as August 26, 2021. Therefore, as the required data element 
admission/start of care date, on this 30-day period of care claim does not match the one-time, artificial 
'admission' date reported on the NOA claim, we find the Medicare rule for reimbursement of this January 23, 
2022, through February 21, 2022, claim has not been met. Therefore, we decided that the Plan does not have to 
pay for the home health services provided to the enrollee from January 23, 2022, to February 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36558 provided on June 1, 2022. 
 
You asked the Plan to pay for the billed services. You say that separate payment is necessary. The Plan denied 
your request. The Plan says the service is included within the global surgery package. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 36558 has a 10-day global surgery period. Code 36558 was previously billed on May 
28, 2022. A modifier was not billed for the date of service at issue to indicate the service was unrelated to the 
original procedure. Based on this information, we decided that Medicare rules for coverage of the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 36558 
provided on June 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 16, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this untimely claim 
reprocessed due to unavoidable circumstances. The Plan denied your request. The Plan says this claim has not 
been billed within the required timeliness window. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until June 15, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on September 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for arthrocentesis injections provided on June 
13, 2022, to June 27, 2022. 
 
You asked the Plan to waive the deductible for arthrocentesis injections. You say that these charges should be 
covered under the office visit which you already paid for. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 
$223.47 deductible for outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers. 
 
You have been asked to pay a $223.47 deductible for arthrocentesis injections. This item/service falls within 
the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers 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 deductible for arthrocentesis injections provided 
on June 13, 2022, to June 27, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you do not have help in the home and need a SNF. 
The Plan denied your request. The Plan says a SNF is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have document skilled nursing or skilled therapy needs. Daily skilled 
services are not required to establish a maintenance program to prevent deterioration of your condition. You 
care needs can be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided on April 29, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that you would like this covered. The Plan 
denied your request. The Plan says this service is not covered when there is no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 29, 2022. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided on April 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you did not know a referral was needed and you 
would like the claim reprocessed for payment. 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 an office visit provided on June 14, 2022, by an 
out-of-network (OON) provider.
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 enrollee would benefit from an 
admission to LTACH to regain a maximum, prior level of functioning and continue multidisciplinary approach 
to care. The Plan denied your request. The Plan says 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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where their currently receiving care. The health plan has approved ongoing care in the current 
acute care setting. 
 
   
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for walking boot provided on June 18, 2021. 
 
You asked the Plan to waive the coinsurance for walking boot. You say that you have only one income and you 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment (DME) and related supplies. 
 
You have been asked to pay 20% coinsurance for walking boot. This item/service falls within the durable 
medical equipment (DME) and related 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 
coinsurance for walking boot provided on June 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
May 18, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service May 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a single photon emission computed tomography 
(SPECT) scan (78803). 
 
You asked the Plan to pre-approve a SPECT scan. The Plan denied your request. The Plan says the records do 
not show that the enrollee's signs and/or symptoms are due to ATTR (amyloid transthyretin) because AL 
(immunoglobulin light chain amyloidosis) has been ruled out. 
 
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 SPECT scan. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the records do not show evidence of ATTR (amyloid transthyretin). Our reviewer found that 
there is no clinical evidence provided to support the performance of SPECT imaging in this enrollee according 
to current guidelines. Our physician reviewer also found that as a result, at this time SPECT imaging would not 
be considered medically reasonable and necessary in this enrollees clinical management. 
 
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 SPECT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a single photon emission computed tomography (SPECT) scan (78803).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array epidural (CPT 63650). 
 
You asked the Plan to pre-approve percutaneous implantation of neurostimulator electrode array epidural. You 
say that percutaneous implantation of neurostimulator electrode array epidural is medically necessary. The Plan 
denied your request. The Plan says under Medicare guidelines, your request is not medically necessary because 
the records show that the enrollee is not a surgical candidate per a neurosurgeon or spinal surgeon. 
 
The Plan follows Medicare rules. Medicare rules say that the implantation of spinal cord stimulators (SCS) may 
be covered as therapies for the relief of chronic intractable pain. 
 
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 percutaneous implantation of 
neurostimulator electrode array epidural. Our reviewer says that percutaneous implantation of neurostimulator 
electrode array epidural is not medically necessary. Our physician reviewer found that the record indicates that 
the enrollee has lumbar spondylosis with radiculopathy. The record indicates that pain has been improved with 
medication therapy. Therefore the enrollee does not have chronic intractable pain.  The elements of the 
coverage criteria are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous implantation of neurostimulator electrode array epidural 
 have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous 
implantation of neurostimulator electrode array epidural.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for compression stockings provided from February 15, 2022, to 
May 11, 2022. 
 
You asked the Plan to pay for compression stockings. You say that you followed the instructions given by the 
Plan and this should result in reimbursement. The Plan denied your request. The Plan says the denial of 
payment for these supplies is correct, because these stockings were not ordered by your treating physician and 
you have not been diagnosed with diabetes. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings billed without a standard 
written order (SWO) will be automatically denied.  
 
We looked at the file and Medicare rules. You did not receive a standard written order (SWO) for these 
compression stockings. Based on this information, we decided that Medicare rules for coverage of compression 
stockings have not been met. Therefore, we decided that the Plan does not have to pay for compression 
stockings provided from February 15, 2022, to May 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
March 3, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service March 3, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for home health agency care provided on 
February 17, 2022, to March 15, 2022. 
 
You asked the Plan to waive the deductible for home health care. You say that you would like claim 
reprocessed with lower cost share. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $750 
deductible for home health care. The allowed amount of these services total $676.49, resulting in a deductible 
amount of $676.49. 
 
You have been asked to pay $676.49 deductible for home health care. This item/service falls within the home 
health care 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 deductible for home health agency care 
provided on February 17, 2022, to March 15, 2022.