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

 
We decided that the Plan does not have to pre-approve an interspinous device placement (22612, 22840). 
 
You asked the Plan to pre-approve the procedure. You say that this procedure is medically necessary. The Plan 
denied your request. The Plan says interspinous devices are experimental at this time and non-covered. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Minuteman spinal device is considered experimental at this time. More research is needed 
to show safety and efficacy of this procedure. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an interspinous device placement (22612, 22840).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient visit for evaluation and management services 
provided on May 5, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an outpatient visit. You say that the enrollee was in an assisted living facility 
when the services were rendered. You say it is highly unusual for an enrollee to choose a doctor in-network in 
the given living situation. Furthermore, you say that when a provider visits a nursing home, the doctor is 
required to see all patients in the facility that need care, regardless of network status. The Plan denied your 
request. The Plan says the services cannot be paid for because the enrollee does not qualify for a coverage 
exception such as emergent or urgent care. The services were not pre-approved, and the provider is not in-
network. 
 
 
 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 an outpatient visit for evaluation and management 
services provided on May 5, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the coinsurance for an immediate maxillary and mandibular 
denture (D5130 and D5140) provided by a participating provider on December 30, 2021. 
 
You asked the Plan to pay the coinsurance for an immediate maxillary and mandibular denture. You say that 
you needed these dentures. The Plan denied your request. The Plan says the correct coinsurance amount has 
been applied. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers an immediate 
maxillary and mandibular denture once every five plan years. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of an immediate maxillary and mandibular denture have been met. The total allowed amount is 
$2,654. The total amount you are being asked to pay is $1,327 ($2,654 x 50% = $1,327).  Therefore, we 
decided that the Plan does not have to pay the coinsurance for an immediate maxillary and mandibular denture 
(D5130 and D5140) provided by a participating provider on December 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 4, 2022 billed with 
codes 81162 and 81319. 
 
You asked the Plan to pay for the genetic testing billed. You say that the enrollee's physician ordered genetic 
testing for the enrollee due to its validated clinical utility in clarifying disease risk. The Plan denied your 
request. The Plan says the claim does not meet Medicare NCD/LCD criteria. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required.  Invitae Prostate cancer panel has not been validated by Palmetto GBA per DEX diagnostics and 
therefore is not covered by Medicare Based on this information, we decided that Medicare rules for coverage of 
the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the 
genetic testing provided on April 4, 2022 billed with codes 81162 and 81319.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical pathology services provided on May 18, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for surgical pathology services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network 
and authorization is required prior to an out-of-network visit. 
 
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 surgical pathology services provided on May 18, 
2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a visual field examination (92083) and scanning 
computerized ophthalmic diagnostic image (92133) provided on April 22, 2022. 
 
You asked the Plan to pay for the vision services. You say that you want the Plan to pay for the services. The 
Plan denied your request. The Plan says until you have met your $500 deductible, you are responsible for 
paying the full cost for services. 
 
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 there is a $500 deductible which applies to vision services.  
 
The item or service you asked the Plan to pay for falls within the benefit category vision services. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to 
vision services. This cost sharing is a contractual obligation that had not been met at the time the vision 
services was received on April 22, 2022. Therefore, we decided that the Plan does not have to pay for a visual 
field examination (92083) and scanning computerized ophthalmic diagnostic image (92133) provided on April 
22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) provided on February 11, 2020. 
 
You asked the Plan to pay for the evaluation and management service. You say that the proper insurance 
information was not provided upon being seen at your facility. The Plan denied your request. The Plan says the 
claim processed correctly. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the evaluation and management service was not filed until February 10, 
2022. This means that more than one calendar year from the date of service had passed before a claim was 
filed. Therefore, we decided that the Plan does not have to pay for the office visit (99203) provided on 
February 11, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for neurology services provided to the enrollee on March 14, 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 records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the technical report states that 95885 
was performed at abductor hallucis, gastric S1, rectus femoris, tibialis anterior L5, and vastus medialis L2-4. 
Therefore, this code is supported. The technical report states that 95908 was rendered as nerve conduction 
studies were performed at simulation sites at recording sites L4 and L5. Therefore, this code is supported. The 
technical report states that 95955, was monitored via modified 10-20 montage throughout the surgical 
procedure. Therefore, this code is supported.  
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
neurology services provided to the enrollee on March 14, 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 pneumatic compression devices (E0651, E0667) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve pneumatic compression devices. You say that the requested items are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for OON 
services have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
pneumatic compression devices (E0651, E0667) to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that this device is medically 
necessary. The Plan denied your request. The Plan says this equipment is non-covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pre-approve a pneumatic compression device (E0676).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the transcatheter implantation of wireless pulmonary 
artery pressure sensor (CardioMEMS) (33289). 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that you are appealing the denial and the 
records should support the necessity of the requested service. The Plan denied your request. The Plan says there 
is not enough evidence showing the requested device would improve the outcome of your condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.   
 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CardioMEMS device have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the transcatheter implantation of wireless pulmonary artery pressure sensor (CardioMEMS) 
(33289).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care services provided on May 18, 
2022. 
 
You asked the Plan to waive the copayment for urgent care services. You say that you do not think you should 
have to pay this copayment since the urgent care did not do anything for you. The Plan denied your request. 
The Plan says you were 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 $65 
copayment for each urgent care visit.  
 
 
 
 
 
 
 You have been asked to pay a $65 copayment for urgent care services. Urgent care services fall within the 
urgently needed 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 urgent care 
services provided on May 18, 2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the emergency ambulance transportation (A0427) and ground mileage 
(A0425) provided on November 1, 2021. 
 
You asked the Plan to pay for the emergency ambulance transportation and ground mileage. You say that you 
would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says that this 
claim processed correctly. The Plan also says the auto carrier's payment and the Plans payment should not 
exceed the Plan's normal allowable amount combined. 
 
The Plan must follow Medicare rules. Medicare rules say that the amount of secondary payment is determined 
by the lowest of three calculations as described in the Medicare rules section of this decision. 
 
1) The actual charge minus the primary payment: $690.25 - $552.20 = $138.05. 
2) The amount the Plan would pay if there were not primary payer: $442.60 (fee schedule total) - $240 (Plan 
cost sharing) = $202.60. 
3) The primary payer allowed amount (which is higher than Medicare) minus the primary payment: $690.25 - 
$552.20 = $138.05. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the emergency ambulance transportation and ground mileage have been met. Specifically, the 
lowest of the three calculations is $138.05, which is the amount that must be paid by the Plan. Therefore, we 
decided that the Plan has to pay for the emergency ambulance transportation (A0427) and ground mileage 
(A0425) provided on November 1, 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 pay for a telephone evaluation and management service provided on 
June 1, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a telephone physician visit. You say that due to the ongoing crisis and staffing 
shortage, a prior authorization could not be obtained before rendering services to the enrollee. The Plan denied 
your request. The Plan says the services were rendered by an out-of-network provider and without a prior 
authorization. The Plan also says that the services were neither urgent nor emergent. Therefore, the requested 
services do not qualify for any of the exceptions listed in the Plan contract. 
 
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 telephone evaluation and management service 
provided on June 1, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on February 15, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that it is the facilities responsibility to obtain 
prior authorization and you would like for the services to be reimbursed. 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 nursing facility care provided on February 15, 
2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on March 4, 2022. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you want the Plan 
to cover the services. The Plan denied your request. The Plan says the Medicare ambulance benefit is a 
transport benefit. If no transport of a Medicare beneficiary occurs, then there is no Medicare covered services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 4, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
(A0998) provided on March 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this device is experimental. More research is needed. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 22, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this should be paid for. 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 April 22, 2022.