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

 
We decided that the Plan does not have to pay for the self-administered drugs rendered on November 23, 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 self-administered drugs are not covered. 
 
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 pay for the self-administered drugs 
rendered on November 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 30, 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 November 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) provided on June 28, 
2021 by an out-of-network (OON) provider. 
 
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 rendered by an out-of-network provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The 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 magnetic resonance imaging (MRI) provided 
on June 28, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Out-of-Network Kidney Transplant 
 
You asked the Plan to pre-approve Out-of-Network Kidney Transplant. You say that you would like to appeal 
the denial of the 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. 
 
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 Out-of-Network Kidney Transplant. 
Our reviewer says that the documentation indicates that the members 
needs can be met in-network therefore, going out of network is not medically necessary. Our physician 
reviewer found There were no unique criteria in records to justify out of network transplantation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Out-of-Network Kidney Transplant have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Out-of-Network Kidney Transplant
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesia for a radiation procedure provided on October 21, 2021, 
by a certified registered nurse anesthetist (CRNA). 
 
You asked the Plan to pay for the CRNA services. You say that this claim was coded correctly for medically 
necessary services. The Plan denied your request. The Plan says that documentation submitted for appeal 
supports this member underwent one anesthesia/operative session on this date. Further review of our claims 
system shows the member underwent two separate anesthesia/operative sessions on this date. Multiple attempts 
to obtain the other anesthesia records 
for date of service were unsuccessful. 
 
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 failed to offer a cogent denial rationale with supporting evidence. 
This claim was denied stating that the service was included in the primary procedure. However, no information 
was provided for which primary procedure payment is included in, nor any evidence of any service being paid 
related to the anesthesia. The records support that the CRNA provided anesthesia care. Without any evidence 
of payment for this to another provider or this provider, we find that denial of payment on the claim at issue is 
not supported. Therefore, we decided that the Plan has to pay for the anesthesia for a radiation procedure 
provided on October 21, 2021, by a certified registered nurse anesthetist (CRNA).  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G device. 
 
You asked the Plan to pre-approve the MyoPro Motion G device. You say that this device is medically 
reasonable and necessary. The Plan denied your request. The Plan says this item is considered 
experimental/investigational. 
 
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 MyoPro Motion G device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not 
in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long term outcomes for this patient, improve hemiparetic arm function, or be safe for 
long term use. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 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 MyoPro Motion G device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the MyoPro Motion G device.
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 your providers agree that you need acute 
rehabilitation. The Plan denied your request. The Plan says criteria for admission to the IRF setting have not 
been met. Your ongoing skilled therapy and nursing needs can be provided at a lower level of care. 
 
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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, conventional air services, transport 
(A0430), and air mileage (A0435) provided on March 11, 2021. 
 
You asked the Plan to pay for the air ambulance services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the air ambulance services were not medically necessary.  
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 the air ambulance services. Our reviewer 
says that the air ambulance services were not medically necessary. Our physician reviewer found the record 
indicates that the enrollee was transported from an acute care facility in Michigan to a rehabilitation facility in 
Indiana for further care following a femur fracture. The record does not support the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. Therefore, the reviewer found that 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 the air ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for the ambulance service, conventional air services, transport (A0430), and air 
mileage (A0435) provided on March 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99152) provided on June 24, 
2021. 
 
You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does 
not support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 We find that CPT code 99152 is not supported in the medical record. Specifically, the documentation submitted 
does not indicate the presence of an independent trained observer to assist in the monitoring of the patient's 
level of consciousness and physiological status. Based on this information, we decided that Medicare rules for 
coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not 
have to pay for moderate sedation services (99152) provided on June 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77002 billed for date of service November 
29, 2021. 
 You asked the Plan to pay for procedure code 77002. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 77002 is bundled into payment for 
code 36556. 
 
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 77002 
is a column II code to column I code 36556. 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 77002 billed for date of service November 29, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99205) and electrocardiogram (93010) 
provided on November 30, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and electrocardiogram. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says prior 
authorization was not obtained by the provider or facility. 
 
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 (99205) and electrocardiogram 
(93010) provided on November 30, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve PET with concurrently acquired CT for attenuation correction and 
anatomical localization imaging; whole body (CPT code 78816). 
 
You asked the Plan to pre-approve the PET scan. You say that the service is necessary. The Plan denied your 
request. The Plan says that the clinical value and effectiveness of a PET scan in the setting of hypercalcemia 
which has normalized following treatment of stage five (5) chronic kidney disease have not been demonstrated 
in the peer-reviewed literature. 
 
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 the PET scan.  Our reviewer says that the requested items/services are considered medically reasonable and necessary in this 
case. Our physician reviewer found as neoplasm strongly is suspected, the PET scan should be approved. 
 
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 PET scan have been met. Therefore, we decided that the Plan has to pre-
approve PET with concurrently acquired CT for attenuation correction and anatomical localization imaging; 
whole body (CPT code 78816).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for comprehensive eye exam (92014) fundus 
photography (92250) provided December 13, 2021. 
 
You asked the Plan to waive the copayment for the vision services. You say that your plan covers one 
refraction per year. Please reconsider and reimburse. The Plan denied your request. The Plan says the claim 
was reprocessed with the correct cost share applied per the Evidence of Coverage. 
 
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 $25 
copayment for in network covered vision services in a specialist's office.  
 
You have been asked to pay $25 copayment for the vision services. The Plan has also approved that you will be 
reimbursed $40 for CPT code 92015. The vision services fall within the Vision 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 copayment for comprehensive eye exam (92014) fundus photography 
(92250) provided December 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power seat elevation system (CPT code E2300). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the power seat elevation feature is denied as not covered. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. The rules say that a power seat 
elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily 
medical in nature. Therefore, we decided that the Plan does not have to pre-approve power seat elevation 
system (CPT code E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cochlear implant device, left ear (CPT code L8614) and 
(CPT code 69930). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the enrollee does not have severe hearing loss since they had a right sided cochlear 
implant in place. 
 
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 services. Our physician reviewer 
found the requested services for left-sided cochlear implantation do not meet criteria for Medicare coverage. 
The health plans criteria for cochlear implantation require a diagnosis of bilateral moderate-to-profound SNHL 
with limited benefit from appropriate hearing or vibrotactile aids. No documentation of comprehensive binaural 
audiometric testing results, dated before or after the right-sided cochlear implantation, was provided other than 
right ear testing on February 12, 2021, to test cochlear implant performance. There was also no documentation 
that the enrollee was deriving limited benefit from their existing cochlear implant. The health plans criteria 
also require evidence of freedom from middle ear infection; there was no pertinent documentation of otoscopic 
examination as part of the enrollees workup for left-sided cochlear implantation. In summary, the requested 
services for left-sided cochlear implantation do not meet Medicare criteria for 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve cochlear implant device, left ear (CPT code L8614) and (CPT code 69930).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office services (CPT code 99205 X 2) to be 
provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The 
Plan denied your request. The Plan says they have providers that are in-network that can treat your condition. 
 
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 
the office services (CPT code 99205 X 2) to be provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (G0483) provided on April 7, 2021. 
 
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this claim was not billed with the correct 
POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the drug testing services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the drug testing services (G0483) provided on April 7, 2021.