Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve evascularization, endovascular, open or percutaneous, 
femoral, popliteal artery(s) (37224), revascularization, endovascular, open or percutaneous, femoral, popliteal 
artery(s), unilateral; with atherectomy, includes angioplasty within the same vessel, when performed (37225), 
revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal 
stent placement(s), includes angioplasty within the same vessel, when performed (37226) and 
revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal 
stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed (37227). 
 
You asked the Plan to pre-approve vascular services. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says the requested services do not meet criteria. 
 
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 vascular services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is a request for treatment of a left SFA stenosis although the duplex 
demonstrates no evidence of left SFA stenosis. The enrollees symptoms are behind the left knee, an unusual 
location for claudication. The enrollee has a history of osteoarthritis, status post left hip replacement. He is 
documented to have normal peripheral pulses and there is no documentation of abnormal ABIs. For the 
procedure to be considered medically necessary, it would need to be evidence of abnormal pulses, abnormal 
ABIs and symptoms that match the physical examination and noninvasive findings. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of vascular services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve evascularization, endovascular, open or percutaneous, femoral, popliteal artery(s) 
(37224), revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with 
atherectomy, includes angioplasty within the same vessel, when performed (37225), revascularization, 
endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent 
placement(s), includes angioplasty within the same vessel, when performed (37226) and revascularization, 
endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent 
placement(s) and atherectomy, includes angioplasty within the same vessel, when performed (37227).
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for outpatient mental health services provided to the enrollee on January 
17, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the primary procedure was processed and paid. 
 
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 not substantiated their denial. The appellant provided a claim for 
the primary procedure. The plan's denial is invalid. Therefore, we decided that the Plan has to pay for 
outpatient mental health services provided to the enrollee on January 17, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the heart (75572) 
provided on September 24, 2021. 
 
You asked the Plan to pay for the CT scan of the heart. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim is considered bundled and not 
eligible for payment. 
 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 75572 
is a column II code to column I code 75574. 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 the computed tomography (CT) scan of the heart (75572) 
provided on September 24, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to provide five additional occupational therapy visits. 
 
You asked the Plan to provide occupational therapy. You say that the patient would benefit from 5 additional 
visits of OT to be completed 1x/week. The Plan denied your request. The Plan says that the records sent to us 
do not support the request for treatment. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 provide occupational therapy. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found Per clinical documentation, not all 
therapy goals have been met and five additional occupational therapy sessions are medically reasonable as it 
would take the professional skill of an occupational therapist to meet documented goals. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of occupational therapy have been met. Therefore, we decided that the Plan has to 
provide five additional occupational therapy visits.  
 
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: Partially Favorable

 
We decided that the Plan has to reduce the copayment for the device evaluation and programming provided on 
March 16, 2022, to $100. We also decided that the Plan does not have to reduce the copayment to $20.  
 
You asked the Plan to reduce the copayment for the device evaluation and programming. You say that you 
were previously charged only a $20 copayment for a specialist visit. The Plan says that you have been charged 
the correct cost sharing amount. 
 
 
 The Plan says that you must pay $100.12 for the device evaluation and programming. Based on the Plan 
contract, however, you cannot be asked to pay more than a $100 copayment for diagnostic procedures and 
tests. The device evaluation and programming falls within the Outpatient Diagnostic Tests and Therapeutic 
Services and Supplies benefit category. Therefore, we decided that the Plan has to reduce the copayment for the 
device evaluation and programming provided on March 16, 2022, to $100. We also decided that the Plan does 
not have to reduce the copayment to $20. 
 
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 pay for the psychotherapy services provided on February 28, 2020, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy services. You say that the facility failed to obtain the proper 
authorization and you would like the claim reprocessed for payment 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. 
 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 psychotherapy services provided on February 
28, 2020, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower limb prosthetics (L5828, L5845, L5856, L5848). 
 
You asked the Plan to pre-approve the lower limb prosthetics. You say that the lower limb prosthetics are 
medically necessary. The Plan denied your request. The Plan says coverage rules are not met. 
 
The Plan follows Medicare rules. Medicare rules say that for coverage of prosthetic knees, coverage is 
extended only if there is sufficient clinical documentation of functional need for the technologic or design 
feature of a given type of knee. 
 
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 lower limb prosthetics. Our 
reviewer says that the requested prosthetic knees are not medically necessary. Our physician reviewer found 
the documentation does not support that the patient is a K3 ambulator and the requested Kenevo knee has 
deluxe features which are not medically necessary for the patient. 
 
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 lower limb prosthetics have not been met. Therefore, we decided that the 
Plan does not have to pre-approve lower limb prosthetics (L5828, L5845, L5856, L5848).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for case management services provided on September 1, 2021, 
by an out-of-network provider. 
 
You asked the Plan to pay for case management services. You say that you are in-network and for some reason 
with the merge this provider was not updated. 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 case management services provided on 
September 1, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a percutaneous implantation of neurostimulator electrode array, 
epidural (63650). 
 
You asked the Plan to pre-approve a percutaneous implantation of neurostimulator electrode array. You say 
that you wish to proceed with the trial to help alleviate these symptoms and provide the enrollee increased 
range of motion and enhanced performance with regard to activities of daily living. The Plan denied your 
request. The Plan says that the requested treatment does not meet the requirements for approval. 
 
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 a percutaneous implantation of 
neurostimulator electrode array. Our reviewer says that the requested items/services are considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic low back pain 
from post laminectomy syndrome. He takes Percocet, Gabapentin, Lrica and Lidocaine ointment. He has failed 
conservative therapy. He has psychiatric clearance for a trial. The enrollee meets the criteria for a SCS trial. 
 
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 percutaneous implantation of neurostimulator electrode array have been met. 
Therefore, we decided that the Plan has to pre-approve a percutaneous implantation of neurostimulator 
electrode array, epidural (63650).  
 
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 a portable ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the request for a home mechanical ventilator set in average volume-assured 
pressure support (AVAPS) mode with AutoEPAP (AE) that could be delivered by bilateral positive airway 
pressure (BiPAP) is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found the enrollee 
was recently hospitalized with heart failure and altered mental status, and an arterial blood gas (ABG) study 
was suggestive of acute on chronic hypercarbic respiratory failure. There is no documentation of chronic obstructive pulmonary disease (COPD) with pulmonary function tests, and no diagnosis of thoracic restrictive 
disease or neuromuscular disease. There is no documentation of chronic CO2 retention with an ABG done 
while stable as an outpatient. If the patient does have chronic CO2 retention, bipap is the appropriate treatment, 
which can provide the AVAPS mode. Medicare does not cover a home ventilator when used as BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a portable ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laparoscopy services coded 49651 provided on January 7, 
2022.  
You asked the Plan to pay for the laparoscopy services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
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 49651 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 the 
laparoscopy services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laparoscopy services coded 49651 provided on January 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a telehealth visit on February 11, 2022. 
 
You asked the Plan to waive the copayment for a telehealth visit. You say that you would like to appeal the 
cost share. The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for a telehealth visit.  
 
You have been asked to pay a $25 copayment for a telehealth visit. A telehealth visit falls within the 
Physician/Practitioner services, including doctors office visits 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 a telehealth visit on February 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone growth device (stimulator) (E0747). 
 
You asked the Plan to pre-approve a bone growth device. You say that the requested bone growth device is 
medically necessary. The Plan denied your request. The Plan says the requested bone growth device does not 
meet criteria. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion 
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs 
have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the 
electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days.  
 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 bone growth device. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found detailed documentation is not 
evident regarding serial x-rays over a 3-month period (evidencing no progressive healing to support the 
diagnosis of non-union at this time.) There is no evidence in the available medical records that you would be 
considered at high risk for delayed fracture healing. Continuation of appropriate conservative fracture 
management was indicated at the time of this request. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
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 bone growth device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bone growth device (stimulator) (E0747).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 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 
services are not medically necessary. Our physician reviewer found although further rehabilitation services 
would be appropriate to improve function, as a practical matter, the intermittent skilled services can be 
provided at a lower level of care than a skilled nursing 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF panel provided on October 25, 2021. 
 You asked the Plan to pay for the Tempus xF panel. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the testing must be FDA approved. 
 
We looked at the file and Medicare rules. Review of the file does not support that the testing rendered was 
FDA approved. Based on this information, we decided that Medicare rules for coverage of the Tempus xF 
panel have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus xF panel 
provided on October 25, 2021.