Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services provided on July 19, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed 
services were not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. We find that CPT code 97530 is not supported in the medical record. The 
records show that the services at issue was provided by an occupational therapy assistant. There is a more 
comprehensive code available to describe the services provided.  
 
 Based on this information, we decided that Medicare rules for coverage of the services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for the therapy services provided on July 19, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pulmonary stress testing, pulmonary diagnostic testing and 
therapies, and pulmonary functioning testing provided on June 23, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for pulmonary stress testing, pulmonary diagnostic testing and therapies, and 
pulmonary functioning testing. You say that you did not receive any type of notification that this was denied. 
The Plan denied your request. The Plan says upon review, you have confirmed that you had diagnostic testing 
rendered with an out-of-network specialist, and they have no approved authorizations on file for you to see this 
out-of-network provider. The Plan also says that they have confirmed with your primary care physician's 
referral department, that they had never received a request to submit a referral or authorization for services with 
this provider. 
 
 
 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 pulmonary stress testing, pulmonary diagnostic 
testing and therapies, and pulmonary functioning testing provided on June 23, 2021 by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an onabotulinumtoxina injection provided 
on November 30, 2021. 
 
You asked the Plan to waive the coinsurance for an injection. You say that if you were advised of the 
coinsurance amount you would not have received the injection. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing amount. 
 
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 Part B drugs.  
 
You have been asked to pay $335.43, which is 20% coinsurance of the allowed amount for an injection 
($1,677.15 allowed amount x 20% coinsurance = $335.43). 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 coinsurance for an 
onabotulinumtoxina injection provided on November 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 21, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the laboratory services. You say that the testing was ordered by the referring 
provider, and you would like reconsideration on the claim. The Plan denied your request. The Plan says the 
rendering and referring providers are both OON providers and there was no 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 laboratory services provided on October 21, 
2021, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the ProAct periurethral balloon 
incontinence device. 
 
You asked the Plan to pre-approve the ProAct procedure. You say that it is felt that this treatment is necessary 
for the enrollee's incontinence. The Plan denied your request. The Plan says this is an experimental procedure 
at this time. 
 
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 ProAct procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is a 78 year old male with prostate cancer treated with robotic radical 
prostatectomy in 2011. He has had urinary incontinence. He has tried Kegel exercises but has not had any 
improvement. He has not had any other treatments.  
 
The ProAct periurethral balloon incontinence device is considered experimental/investigational. Clinical trials 
show significant complications from the device and questionable clinical outcomes, and open clinical trials persist to evaluate the long-term incidence of complications such as urethral stricture and device erosion. In 
addition, there is no documentation that this service is at least as beneficial as an existing and available 
medically appropriate alternative.  
 
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 ProAct procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of the ProAct periurethral balloon incontinence device.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an abdominal ultrasound (76705) provided on February 1, 
2022. 
 
You asked the Plan to pay for an abdominal ultrasound. You say that you have provided records to support the 
service billed. The Plan denied your request. The Plan says rules for payment have not been met because the 
CPT code at issue is inclusive to another billed code. 
 
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 an abdominal ultrasound (76705) provided on February 1, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided on January 30, 2022, to 
February 2, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was medically 
necessary. The Plan denied your request. The Plan says that the enrollee does not meet the criteria for 
admission due to a UTI. 
 
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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee was not medically safe for discharge until February 2, 2022. Given the information 
provided, the enrollee does meet the criteria for an inpatient hospital admission 
 
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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided on January 30, 2022, to February 2, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek Aviva Plus In Vitro strips. 
 
You asked the Plan to pre-approve Accu-Chek Aviva Plus In Vitro strips. 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 the rules say that plans may specify brands and 
manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to 
only those preferred brands and manufacturers as long as the enrollee retains access to all medically necessary 
items (including non-preferred brands). 
 
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 Accu-Chek Aviva Plus In Vitro strips. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the record does 
not indicate why the enrollee cannot use the plan's preferred manufacturers. The record provided does not 
establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The 
elements of the coverage criteria are not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Accu-Chek Aviva Plus In Vitro strips have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Accu-Chek Aviva Plus In Vitro strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 wheelchair with multiple power options and 
upgraded electronics coded as K0861 E2361, E1028, E1007, E2620, E0955, E1028, E1012, E2377, E2311, 
E2313, E2323, E2622. 
 
You asked the Plan to pre-approve the power wheelchair. You say that please review the attached medical 
documentation to support the need of the custom medical equipment being requested for the enrollee. The Plan 
denied your request. The Plan says the enrollee does not have a medical need for multiple power options a 
group 3 power wheelchair with no power options can be reviewed if requested. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a neurologic disorder with functional deficits. He meets criteria for 
use of a power mobility device. The requested accessories are not medically necessary as he does have use of 
his hands therefore would not require upgraded electronic features. Furthermore, the documentation does not 
indicate that the member has any pressure injuries or requires intermittent catheterization of the bladder 
therefore the power tilt and recline would not be 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 power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a group 3 wheelchair with multiple power options and upgraded electronics coded 
as K0861 E2361, E1028, E1007, E2620, E0955, E1028, E1012, E2377, E2311, E2313, E2323, E2622.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the clinical visit provided on February 1, 2022, by an OON 
provider. 
 
You asked the Plan to pay for the clinical visit. You say that you would like reconsideration of the claim based 
on medical necessity. 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 clinical visit provided on February 1, 2022, by 
an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428), and ground mileage (A0425) provided on December 18, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the transport was medically necessary. The 
Plan denied your request. The Plan says the enrollee did not require monitoring during the transport. The Plan 
also says that the ambulance services were not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance services. Our reviewer says 
that the ambulance services were not medically necessary. Our physician reviewer found the provided 
documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, 
private car, or other type of vehicle) were contraindicated for the enrollee. The reviewer found that the 
provided documentation does not support that the enrollee needed the expertise, services and lifesaving and 
life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. The reviewer 
found also that the documentation does not support that the ambulance transport on December 18, 2021 was medically reasonable and necessary for the enrollee. 
 
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 ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428), and 
ground mileage (A0425) provided on December 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the x-ray and ultrasound provided on 
January 10, 2022. 
 
You asked the Plan to waive the copayment for the x-ray and ultrasound. You say that you were told it would 
only be $25 for all 3 exams performed. The Plan denied your request. The Plan says the copayment was applied 
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 $15 
copayment for each Medicare-covered standard X-ray service and a $115 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). 
 
You have been asked to pay a total of $130 for the x-ray and ultrasound. The x-ray falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category.  The ultrasound falls within the 
Other outpatient diagnostic tests  Radiological diagnostic services, not including x-rays 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 the x-ray and ultrasound provided on January 10, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation services (A0426, A0425) 
provided on December 28, 2021. 
 
You asked the Plan to pay for the ambulance transportation. You say that these services were medically 
necessary, as the enrollee had sepsis and was unable to tolerate a seated position for the time required to 
transport. The Plan denied your request. The Plan says this claim was billed with an inappropriate principal 
diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that a code from subcategory R65.2 can never be assigned as a principal diagnosis. 
 We find that Medicare billing guidelines for coverage of the ambulance transportation have not been met. 
Specifically, this claim was billed with R65.20, which is an R65.2 subcategory code, as a principal diagnosis. 
Therefore, we decided that the Plan does not have to pay for the ambulance transportation services (A0426, 
A0425) provided on December 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept Procedure. 
 
You asked the Plan to pre-approve the Intracept Procedure. You say that you would like reconsideration 
because this procedure fills a treatment gap for patients that do not receive adequate relief from traditional 
conservative methods, and don't have instability to indicate fusion is the appropriate treatment. The Plan denied 
your request. The Plan says there is a lack of sufficient evidence to establish safety/efficacy, intraosseous 
radiofrequency ablation (Intracept). 
 
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 Intracept Procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found documentation was/is lacking regarding reasonably detailed and/or evidenced 
findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of the 
enrollees chronic persistent pain. Documentation does not support actual formal surgical ablation of pre-
designated basivertebral nerves as being medically necessary and/or reasonable at this time. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. 
 
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 Intracept Procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept Procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 24 additional acupuncture visits. 
 
You asked the Plan to pre-approve 24 additional acupuncture visits. You say that the enrollee is not fully 
recovered at this moment and has already reached the limit for this specific benefit. You say that the enrollee's 
quality of life could be jeopardized if she does not receive the full and proper treatment. The Plan denied your 
request. The Plan says the benefit for acupuncture has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. The records show that the acupuncture you are requesting is for 
treatment of problems with your facial nerves and not for CLBP. This means that your coverage for 
acupuncture to treat this condition is limited to 12 visits per year. Based on this information, we found that your 
request for 24 acupuncture visits exceeds the benefit allowance for your condition. Therefore, we decided that 
the Plan does not have to pre-approve 24 additional acupuncture visits.