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

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the brain for the 
enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation of need for this MRI, or indication of why a computed 
tomography (CT) scan cannot be done. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found the enrollee has no 
focal neurological deficit, and no indication for MRI of the brain. The weakness is not quantified or specified. 
The medical necessity of the MRI has not been established. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the brain for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for colorectal gene panel testing provided on August 20, 2020. 
 
You asked the Plan to pay for panel testing. You say that this testing was medically necessary to assist in 
treatment, prognosis, and diagnosis. The Plan denied your request. The Plan says the denial of payment for this 
testing is correct, because panel testing constitutes a single procedural service so a single procedure code must 
be submitted for the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that a laboratory procedure producing multiple 
reportable results should be reported with a single procedure code.  
 
We looked at the file and Medicare rules. This panel testing was not billed with the appropriate single 
procedure code. If no single procedure code identifies this testing, it may be billed with a miscellaneous or 
unlisted procedure code with a single unit of service. Based on this information, we decided that Medicare rules 
for coverage of panel testing have not been met. Therefore, we decided that the Plan does not have to pay for 
colorectal gene panel testing provided on August 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of inpatient psychiatric care from April 
30, 2022, forward. 
 
You asked the Plan to pre-approve the continuation of inpatient psychiatric care. You say that this care remains 
medically necessary. The Plan denied your request. The Plan says the criteria for coverage of inpatient 
psychiatric care are no longer met. 
 
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 the continuation of inpatient psychiatric 
care. Our reviewer says that the requested continuation of inpatient psychiatric care is not medically reasonable 
and necessary. Our physician reviewer found that the enrollee is a 59-year-old male who was admitted to the 
acute inpatient psychiatric hospitalization on April 25, 2022 with Bipolar Disorder Type I, Current Episode 
Mixed, Unspecified. Based upon review the records provided it was not expected this enrollee would improve 
in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or 
others, no auditory or visual hallucinations and no aggressive behaviors. This patient was compliant and 
cooperative with treatment. It did not appear medically necessary and reasonable to have psychiatric care 
provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as he 
did not have any suicidal or homicidal thoughts, hallucinations or aggressive behaviors. 
 
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 continuation of inpatient psychiatric care have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the continuation of inpatient psychiatric care from April 30, 
2022, forward.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on October 4, 
2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that that you spoke to the doctor's 
office rep, and they informed you your ultrasound was not a radiology procedure. The Plan denied your 
request. The Plan says the copayment 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 $125 
copayment for ultrasounds.  
 
You have been asked to pay a $125 copayment for the 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 the ultrasound provided on October 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on November 
18, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you feel you should not have 
to pay this copayment because the hospital was going to admit you but could not and transferred you to a 
different hospital. You also say you were told you would not pay anything for the ambulance ride and are now 
getting a bill. 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 $225 
copayment for ground ambulance services. The contract also says that the copayment is not waived even if you 
are admitted to a hospital as an inpatient immediately following the ambulance transport.  
 
According to the EOC, You have been asked to pay a $225 copayment for ambulance services. Ambulance 
services fall within the Ambulance Services benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for ambulance services provided on November 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for dialysis training provided by a network 
provider from October 4, 2021, to October 25, 2021. 
 
You asked the Plan to waive the coinsurance for the dialysis training. You say that you thought the dialysis 
training was free. The Plan denied your request. The Plan says you have been asked to pay 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 services to treat kidney disease.  
 
 You have been asked to pay $786.48 which is 20% of the allowed amount for the dialysis training. The allowed 
amount is $3,932.40. ($3,932.40 x 20% = $786.48). The dialysis training falls within the Services to treat 
kidney disease 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 dialysis training provided 
by a network provider from October 4, 2021, to October 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transitional care management services and a domiciliary or 
rest home visit provided on November 10, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for transitional care management services and a domiciliary or rest home visit. You 
say that the provider was not responsible to obtain authorization, and the assisted living facility is responsible 
to obtain prior authorization for all of their patients. 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 transitional care management services and a 
domiciliary or rest home visit provided on November 10, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve speech therapy (ST) services (92507). 
 
You asked the Plan to pre-approve speech therapy. You say that these services are necessary because you have 
a history of strokes and traumatic brain injury. The Plan denied your request. The Plan says the records do not 
support the medical necessity of the requested speech therapy services. Documentation does not show that you 
have a significant loss of function or a problem that supports more skilled treatment with a licensed 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 speech therapy. 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 that based on the medical records provided, there is no documentation 
that the requested therapy is generally accepted as specific and effective therapy for your condition. You appear 
to be performing at a functional level with your documented testing, and further skilled speech therapy at this 
point does not appear to be likely to achieve any significant improvement in your symptoms or functional 
status. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of speech therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve speech therapy (ST) services (92507).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet medical necessity criteria for the requested item. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for Anesthesia for percutaneous image guided procedures on the spine and 
spinal cord; therapeutic (01936) provided March 4, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that please review and reprocess this claim 
according to the CMS guidelines. The Plan denied your request. The Plan says that the service does not meet 
the coverage requirements in the applicable local coverage determination or national coverage determination. 
 
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 directly address and substantiate their reason to deny the 
claim. The Plans reason to continue to deny is not clear. The Plan did not forward the claim submitted by the 
provider so we cannot see how the claim was billed and medical records provided was 1 page that was not 
legible. Therefore, we decided that the Plan has to pay for Anesthesia for percutaneous image guided 
procedures on the spine and spinal cord; therapeutic (01936) provided March 4, 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 pre-approve a repeat facet joint injection. 
 
You asked the Plan to pre-approve a repeat facet joint injection. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says the criteria for coverage of the second facet joint 
injection have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that in order for a second facet joint injection to be 
approved, there must have been at least 80% relief of primary pain.  
 
We looked at the file and Medicare rules. In this case, the documentation specified that the first facet joint 
injection only resulted in 50% pain relief. Based on this information, we decided that Medicare rules for 
coverage of a repeat facet joint injection have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a repeat facet joint injection.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 3, 
2022. 
 You asked the Plan to pay for procedure code 70496. 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 January 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on December 8, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the office visit provided on December 8, 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 copayment for an ophthalmology specialist office visit 
provided on October 7, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you sought early 
confirmation that the outpatient surgery copayment was all you were going to pay. You also say that you were 
ordered to attend a pre surgery preparation visit and that should be included in the surgery 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 $40 
copayment for a specialist office visit.  
 
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$40 copayment for a specialist office visit. A specialist office 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 an ophthalmology specialist office visit provided on October 7, 2021.  
 
Your complaint about the customer service is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service November 7, 
2021. 
 
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 procedure code 76705 billed for date of service November 7, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Leuprolide acetate injection received 
on January 3, 2022. 
 
You asked the Plan to waive the coinsurance for the Leuprolide acetate injection. You say that you have never 
had to pay for this service before. 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 chemotherapy drugs.  
 
 
 You have been asked to pay $240.88 ($1,204.40 x 20%) for the Leuprolide acetate injection. The Leuprolide 
acetate 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 the Leuprolide acetate injection received on January 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a continuous positive airway pressure 
device (CPAP), humidifier, and supplies provided on November 8, 2021, and November 11, 2021. 
 
You asked the Plan to waive the coinsurance for a CPAP device, humidifier, and supplies. You say that the 
provider insisted on sending you the supplies and did not tell you that you would have to pay 20%. 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 durable medical equipment.  
 
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
total of $61.39, which is 20% coinsurance for a CPAP device, humidifier, and supplies.  
 
Date of Service CPT Code Allowed Amount 20% Coinsurance 
November 8, 2021 E0562 $15.34 $3.07 
November 8, 2021 E0601 $48.38 $9.68 
Total  $12.75 
 
November 11, 2021 A7035 $18.54 $3.71 
November 11, 2021 A7037 $17.89 $3.58 
November 11, 2021 A7038 $15.33 $3.07 
November 11, 2021 A7039 $6.72 $1.34 
November 11, 2021 A7030 $98.97 $19.79 
November 11, 2021 A7046 $11.28 $2.26 
November 11, 2021 A7031 $74.44 $14.89 
Total  $48.64 
 
Grand Total  $61.39 
 
A CPAP device, humidifier, and supplies falls within the Durable Medical Equipment (DME) and Related 
Supplies benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a continuous positive 
airway pressure device (CPAP), humidifier, and supplies provided on November 8, 2021, and November 11, 
2021.