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

 
We decided that the Plan has to pre-approve the services (01936) provided on October 19, 2021. 
 
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says that this service 
does not meet the coverage requirement in the applicable Local Coverage Determination (LCD) or National 
Coverage Determination (NCD). 
 
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 argues that the service does not meet the coverage requirement in the 
applicable Local Coverage Determination (LCD) or National Coverage Determination (NCD). However, the 
Plan does not indicate which LCD/NCD coverage criteria have not been met. Without a detailed denial 
rationale and supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that 
the Plan has to pre-approve the services (01936) provided on October 19, 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 an implantable pulse generator. 
 
You asked the Plan to pre-approve an implantable pulse generator. You say that this is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says the evidence at this time is insufficient to 
determine the effects of the requested services on health outcomes. 
 
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 an implantable pulse generator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found at issue is whether implantation of the cardiac contractility modulation 
(CCM) system in this patient is medically necessary for the treatment of congestive heart failure (CHF) which 
has been deemed refractory to optimal medical therapy. An exhaustive review of the current medical literature 
pertaining to the CCM system confirms multiple observational studies suggesting clinical benefit from CCM. 
Several randomized clinical trials of CCM versus control have also been reported, along with meta-analysis 
pooling the data from multiple studies, with CCM providing meaningful improvement in quality-of-life scores 
and objective functional capacity. While the clinical studies led to FDA approval in 2019, CCM remains the subject of multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded 
trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to 
presume clinical outcomes and benefit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an implantable pulse generator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an implantable pulse generator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for a resin-based composite (dental code 
D2393) provided on December 9, 2021. 
 
You asked the Plan to waive the cost-sharing for resin-based composite. You say that you were shocked when 
you received this bill and do not think the Plan paid the correct amount. The Plan denied your request. The Plan 
says the cost-sharing amounts you are being charged are 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 $100 
deductible and 20% coinsurance for resin-based composite. At the time this claim was processed, $0 of the 
$100 deductible had been met. The allowed amount of this service is $116, resulting in a deductible amount of 
$100 which met the $100 total deductible for 2021. The remaining allowed amount of the claim is $16, 
resulting in a coinsurance amount of $3.20. Therefore, the Plan issued a payment of $12.80. As this dentist is 
out-of-network with the Plan, the Plan cannot prevent the provider from balance billing you for the non-
allowed portion of the claim. 
 
You have been asked to pay $100 deductible and 20% coinsurance for resin-based composite. Resin-based 
composite falls within the Optional Supplemental Dental 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 cost-sharing for a resin-based composite (dental code D2393) provided on December 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on February 24, 
2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you should not have to pay because 
the provider did not try to assist with your pain. The Plan denied your request. The Plan says you have been 
charged the correct copayment 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 per specialist visit.  
 
You have been asked to pay a $40 copayment for an office visit. The office visit falls within the 
Physician/Practitioner services, including doctor's 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 office visit provided on February 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 16, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you were not aware of the requirement of 
obtaining a prior authorization, specifically for this member's plan type at the time of rendering services. The 
Plan denied your request. The Plan says the rendering provider is a non-participating provider, and the referring 
provider involved in these services is a non-participating provider with the Plan. The Plan also says that they 
did not authorize any services for neither the rendering nor the referring provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on February 16, 
2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy and skilled nursing services provided to the 
enrollee from February 23, 2021 to August 26, 2021. 
 
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 as of February 2021, the enrollee appeared to have limited mental health symptoms, and only 
anxiety and mild depression were reported. 
 
The Plan must follow Medicare rules. Medicare rules say that adjustment reactions or dysphoria associated 
with moving to a nursing facility do not constitute medical necessity for psychological testing.  
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee appeared to have issues around being at the nursing facility, as she seemed okay with her 
roommate, and was to be transferred closer to her children. Adjustment disorder associated with placement in a 
nursing home is not coverable for these services. The enrollee does not have evidence of a more serious mood 
disorder. The medical record showed her to deny any psychiatric history, suicidal ideation, history of suicide 
attempts but was rather calm and cooperative, friendly, engaging, compliant with medication and treatment. 
This patient exhibited no behavioral disturbance. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for psychotherapy and skilled nursing services provided to the enrollee from February 23, 2021 to 
August 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an injection procedure for sacroiliac joint (27096). 
 
You asked the Plan to pre-approve an injection procedure for sacroiliac joint. The Plan denied your request. 
The Plan says a sacroiliac joint injection does not meet the Plan's Medical Policy coverage 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 an injection procedure for sacroiliac 
joint. Our reviewer says that an injection procedure for sacroiliac joint is not medically necessary. Our 
physician reviewer found that there is no physical exam tests of the SI joint documented.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an injection procedure for sacroiliac joint have not been met.  
 
 
  
Therefore, we decided that the Plan does not have to pre-approve an injection procedure for sacroiliac joint 
(27096).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for diagnostic mammography provided on 
January 14, 2022. 
 
You asked the Plan to waive the deductible for diagnostic mammography. You say that you were told that they 
needed extra films. You say that you did not know this was a separate mammogram that you would have to pay 
for. The Plan denied your request. The Plan says the deductible applied correctly. 
 
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 $750 deductible which applies to outpatient hospital services.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
hospital services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible which applies to outpatient hospital services. This cost sharing is a contractual obligation that had 
not been met at the time diagnostic mammography was received on January 14, 2022. Therefore, we decided 
that the Plan does not have to waive the deductible for diagnostic mammography provided on January 14, 
2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility discharge management service (99316) 
provided on November 12, 2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that the claim should be paid. 
The Plan denied your request. The Plan says the enrollees claim would be covered under Original Medicare as 
it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the nursing facility discharge management service (99316) 
provided on November 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a Veriflex device (22869). 
 
You asked the Plan to pre-approve the insertion of a Veriflex device. You say that this is medically necessary. 
The Plan denied your request. The Plan says this is experimental. 
 
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 insertion of a Veriflex device. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found current evidence based medical guideline and peer reviewed literature do not 
fully support the spinal decompression device procedure over the gold standard of lumbar laminectomy. 
There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for 
this enrollees medical condition. 
 
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 insertion of a Veriflex device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the insertion of a Veriflex device (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ECG provided on January 19, 2022. 
 
You asked the Plan to waive the copayment for an ECG. You say that you feel the balance of $15.63 should be 
paid between insurance and the provider. The Plan denied your request. The Plan says you have been charged 
the correct copayment 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 $30 
copayment for Medicare-covered non-radiological diagnostic services. Examples include, but are not limited to 
EKG's, pulmonary function tests, home or lab-based sleep studies, and treadmill stress tests.  
 You have been asked to pay $15.63 which is less than the standard $30 copayment. The ECG falls 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 ECG provided on January 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 10, 
2022. 
 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 February 10, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee has already had two courses of injections. 
 
The Plan must follow Medicare rules. Medicare rules say that repeat intra- articular injections of sodium 
hyaluronate (Euflexxa) for shoulder arthritis are limited to a single repeat course. 
 
We looked at the file and Medicare rules. The records show that the enrollee has previously had an initial and 
repeat course of injections. Based on this information, we decided that Medicare rules for coverage of Euflexxa 
have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an anticoagulant management visit 
provided on February 1, 2022. 
 
You asked the Plan to waive the copayment for an anticoagulant management visit. You say that only results 
were provided to the doctor and no other services were rendered. 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 $45 
copayment for an anticoagulant management visit with a specialist.  
 
The medical record shows you had an anticoagulant management visit on February 1, 2022. You have been 
asked to pay the allowed amount of $11.13, which is less than the $45 copayment for an anticoagulant 
management visit. An anticoagulant management 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 anticoagulant management visit provided on 
February 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the rendering provider is a non-participating provider, and there is no 
referring provider involved in these services. The Plan also says that they did not authorize any services for this 
provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on February 15, 2022, 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 70480-26 billed for date of service January 
19, 2022. 
 You asked the Plan to pay for procedure code 70480-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 70480 is bundled into payment 
for code 70450. 
 
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 70480 
is a column II code to column I code 70450. 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 70480-26 billed for date of service January 19, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Pathology services provided on December 15, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for 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 it was 
determined these services were not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for Pathology services provided on December 15, 
2021 by an out-of-network (OON) provider.