Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 64719-59-RT billed for date of service October 29, 
2021. 
 
You asked the Plan to pay for procedure code 64719-59-RT. You say that the medical records support separate 
payment of this code. The Plan denied your request. The Plan says that use of the -59 modifier for procedure 
code 64719-59-RT is not supported in the medical record. This service is inclusive to codes 64718-RT and 
64721-RT from the same date of service that were paid. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 procedure code 64719-59-RT Our reviewer 
says that the usage of the -59 modifier is supported in this case to allow for separate payment of this code. Our 
physician reviewer found the operative report describes treatment on the ulnar nerve, which is separate from 
the median nerve. No documentation was found to support these procedures are inclusive, and therefore should 
be covered separately. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 64719-59-RT have been met. Therefore, we decided that the 
Plan has to pay for procedure code 64719-59-RT billed for date of service October 29, 2021.  
 
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 waive the coinsurance for the injection provided on August 17, 2021. 
 
You asked the Plan to waive the coinsurance for injections. You say that this charge should be covered. The 
Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for Part B drugs that are administered by a provider.  
 
You have been asked to pay $1429.88 which is 20% of the allowed amount for the injections. The allowed 
amount is $7199.42(20% x 7199.42 = 1429.88). Injections fall 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 the injection provided on 
August 17, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on January 27, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that the test was necessary so it should 
be covered. 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 $130 
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 $81.25 which is less than the standard $130 copayment for an ultrasound. 
Ultrasounds fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for an ultrasound provided on January 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient mental health admission. 
 
You asked the Plan to pre-approve inpatient mental health admission. You say that the admission is medically 
necessary. The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 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 inpatient mental health admission. Our 
reviewer says that the inpatient mental health admission is not medically necessary. Our physician reviewer 
found the records provided for the admission of the enrollee does not meet criteria for acute inpatient mental 
health treatment as the enrollee was not shown to be a danger to himself or others, no auditory or visual 
hallucinations. The reviewer found that the enrollee is noted to be cooperative and compliant with treatment 
while not showing any aggressive behaviors. Therefore, the reviewer found that the admission is not medically 
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 inpatient mental health admission have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an acute inpatient mental health admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to 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 you have not made any functional gains with therapy and are dependent level for a 
long time and is unlikely to make a significant functional change in the predicted 7-10 days in a short term IRF. 
You do not need intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per week 
with multidisciplinary approach in an IRF. Your rehab needs can be safely provided in a lower intensity and 
alternate setting such as in a skilled nursing facility with intermittent therapies. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a specialist office visit provided on December 14, 2021. 
 
You asked the Plan to pay for the specialist office visit. You say that the enrollee's PCP referred the enrollee to 
you and no one in the PCP office knew how to do a proper referral. The Plan denied your request. The Plan 
says that the rendering provider is an OON provider and there was no referring provider. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the specialist office visit by a contract provider. The file does not show that the 
plan provided notice that the specialist office visit would not be covered. Under Medicare rules, this means the 
specialist office visit is considered approved by the plan. Therefore, we decided that the Plan has to pay for a 
specialist office visit provided on December 14, 2021.  
  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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve insertion of ILR. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that insertion of ILR is only covered for certain 
indications. 
 
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 insertion of ILR. Our reviewer says that 
the documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found the enrollee had a stroke. The enrollee has no history of atrial fibrillation, nor were 
any significant cardiac arrhythmias noted on ECG monitoring. A recent randomized clinical trial found that 
continuous monitoring for atrial fibrillation with an ILR (followed by treatment with oral anticoagulation if 
atrial fibrillation was detected) was not superior to usual care in reducing stroke or systemic embolism among 
patients at high risk of stroke but without a known prior history of atrial fibrillation. At this time, insertion of 
an ILR would not be considered medically appropriate 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 insertion of ILR have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of implantable loop recorder (ILR).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that physical therapy is the only thing that 
works for you. The Plan denied your request. The Plan says the documentation does not indicate that you 
require further treatment of your condition by a physical therapist. 
 
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 pre-approve additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the provided documentation indicates that you have previously been 
treated with outpatient therapies and should be independent with a home exercise program. The reviewer found 
that there is no documentation of a recent injury or decline in function. Therefore, the reviewer found that 
additional therapy services are not an appropriate duration and frequency for treatment of your medical 
condition and therefore are not medically 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 additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 10 additional physical therapy (PT) visits.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the open treatment of radiocarpal or intercarpal dislocation (25670) 
provided on July 16, 2021. 
 
You asked the Plan to pay for the open treatment of radiocarpal or intercarpal dislocation (25670). You say that 
the attached operative notes confirm the procedures were performed and the codes should be reprocessed for 
reimbursement. The Plan denied your request. The Plan says that CPT code 64722 has been overturned and the 
documentation does not separately support CPT 25670-XU. 
 
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 25670 
is a column II code to column I code 25320; however, 25670 was billed with a modifier. 
 
We asked our coder 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 open treatment of radiocarpal or intercarpal dislocation 
(25670). Our reviewer says that the documentation submitted was reviewed and meets the criteria for coverage. 
Our reviewer found the operative report describes two procedures performed through two separate incisions 
that would be reported separately. In this case, the procedures should be covered separately. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the open treatment of radiocarpal or intercarpal dislocation (25670) have been 
met. Therefore, we decided that the Plan has to pay for the open treatment of radiocarpal or intercarpal 
dislocation (25670) provided on July 16, 2021.  
  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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of sperm cord lesion (55520) provided on 
November 30, 2021. 
  You asked the Plan to pay for the removal of sperm cord lesion (55520). You say that CPT code 55520 can be 
coded along with 49521 when modifier XU is used. You say that the attached records should be reviewed and 
CPT code 55520 processed toward payment. The Plan denied your request. The Plan says CPT code 55520 is 
included in CPT code 49521 and cannot be separately reimbursed. 
 
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 55520 is a column II code to column I code 49521; however, 55520 
was billed with a modifier.  
 
We asked our coder 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 removal of sperm cord lesion (55520). Our reviewer says 
procedure code 55520 is not supported as a non-over lapping service. Our reviewer found that the enrollee was 
primarily brought into the operating room for the repair of the recurrent hernia. While there was an incidental 
finding of a lipoma on the cord, this body structure was already being reviewed and manipulated in part of the 
hernia repair. Therefore, the requirements for the procedure to be reported separately are not met. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the removal of sperm cord lesion (55520) have not been met. Therefore, we 
decided that the Plan does not have to pay for the removal of sperm cord lesion (55520) provided on November 
30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MyoPro Motion G Orthotic device. 
 
You asked the Plan to pre-approve MyoPro Motion G Orthotic device. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested item is not medically 
necessary. 
 
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 MyoPro Motion G Orthotic device. 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 weakness and spasticity in the right upper extremity. The 
requested device is used for the upper extremity. It is an arm brace that is motorized and can help an individual 
with upper extremity weakness to move their arm and hand. The requested device has not been shown to be 
superior to other standard treatments for the medical condition. The studies do not indicate the MyoPro brace 
improves an individuals function or general health. Therefore, the requested device is not medically 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 MyoPro Motion G Orthotic device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve MyoPro Motion G Orthotic device.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an ultrasound provided on January 7, 2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you should be charged at the in-
network rate. The Plan denied your request. The Plan says that the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay $0 copayment for basic radiological services at a specialists 
office. 
 
The Plan says you must pay $180 copayment for advanced imaging services done in a specialist's office. An 
ultrasound is considered a basic radiological service. The Plan contract clearly says that you pay a $0 
copayment for basic radiological services at a specialists office. Therefore, we decided that the Plan has to 
waive the copayment for an ultrasound provided on January 7, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a spinal injection provided on September 
17, 2021. 
 
You asked the Plan to waive the copayment for an injection. You say that you already paid the $40 copayment 
and should not have to pay a $325 copayment. 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 a $325 
copayment for outpatient surgery at an ambulatory surgical center.  
 
The record shows a spinal injection is considered a surgical procedure and an outpatient surgery cost share 
applies. You have been asked to pay a $325 copayment for an injection. An injection 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 copayment for a spinal injection provided on September 17, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on November 8, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the assisted living facility is 
responsible to obtain prior authorization for all of their patients, which should also cover for the medical 
treatments provided by this provider. The Plan denied your request. The Plan says this provider is out-of-
network with the Plan, and authorization was not obtained prior to the services being rendered. 
 
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 a domiciliary or rest home visit provided on 
November 8, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 7, 
2021. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service November 7, 
2021.