Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lift chair for the enrollee. 
 
You asked the Plan to pre-approve the chair. You say that this is medically necessary. The Plan denied your 
request. The Plan says the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
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 chair. Our reviewer says that the 
requested chair is not medically reasonable or necessary. Our physician reviewer found the documentation does 
not reveal objective imaging evidence of documentation of (a) severe arthritis of the hip or knee and/or (b) a 
neuromuscular disease. The seat lift is not likely to (a) effect improvement in the patient's condition; or (b) 
arrest or retard deterioration in the patient's condition. The records do not show that the patient is totally 
incapable of standing from a chair in the home. There is no description or reference to the patient's ability to ambulate in the documentation. 
 
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 chair have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a lift chair for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoperative neuromonitoring (IONM) services 
provided on April 13, 2021, billed with codes 95907, 95885, and 95999. 
 
You asked the Plan to pay for the IONM-related services as billed. You say that the services rendered were 
correctly billed and should be paid. The Plan denied your request. The Plan says this claim is not coded 
correctly. 
 
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, the CPT Code Manual definition of code 95907 is nerve conduction studies, 1-2 studies. The code 
definition for 95885 is needle electromyography, each extremity, with related paraspinal read, when performed, 
done with nerve conduction,  amplitude and latency/velocity; limited. Code 95999 is defined as Unlisted 
neurological or neuromuscular diagnostic procedure. 
 
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 IONM-related services as billed. Our reviewer says that 
the records do not support these codes. Our reviewer found for 95907, the procedure report describes pedicle 
screw stimulation. Nerve conduction study procedure would not be reported for the procedure documented. 
Code 95885 is "done with nerve conduction". In this case, nerve conduction study cannot be verified, meaning 
this procedure would not be covered. It is inappropriate to bill separately for train-of-four (TOF) monitoring, 
which is how 95999 is being used. This procedure is inclusive to the primary neuromonitoring procedure. 
 
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 IONM-related services as billed have not been met. Therefore, we decided 
that the Plan does not have to pay for the intraoperative neuromonitoring (IONM) services provided on April 
13, 2021, billed with codes 95907, 95885, and 95999.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcatheter mitral valve repair (33418) provided on 
April 23, 2021. 
 
You asked the Plan to pay for the transcatheter mitral valve repair (33418). You say that the attached medical 
records should be reviewed to reprocess the claim for payment. The Plan denied your request. The Plan says a 
valid clinical trial number was not billed on the claim. 
 
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, the CPT Code Manual definition of code 33418 is transcatheter mitral valve repair, percutaneous 
approach, including transseptal puncture when performed; initial prosthesis. 
 
  We find that CPT code 33418 is not supported in the medical record. Specifically, a valid clinical trial number 
was not billed. Based on this information, we decided that Medicare rules for coverage of the transcatheter 
mitral valve repair (33418) have not been met. Therefore, we decided that the Plan does not have to pay for the 
transcatheter mitral valve repair (33418) provided on April 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for myocardial perfusion imaging provided on 
December 22, 2021. 
 
You asked the Plan to reduce the copayment for myocardial perfusion imaging. You say that you expected the 
Plan to cover the service in full or at 80%, except for the myocardial perfusion imaging. 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 in-network diagnostic radiology services.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$225 copayment for myocardial perfusion imaging. Myocardial perfusion imaging 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 reduce the copayment for myocardial perfusion imaging 
provided on December 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Dental services from January 16, 2021 
through February 14, 2022. 
 
You asked the Plan to waive the copayment for Dental services. You say that you would like to appeal the cost 
share. The Plan denied your request. The Plan says the copayment applied was 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 $10 
copayment per service for Dental services. The total cost share for dental services received between Dental 
services from January 16, 2021 through February 14, 2022 is $70. 
 
You have been asked to pay $10 copayment per service for Dental services. Dental services fall within the 
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 copayment for Dental services from 
January 16, 2021 through February 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the ankle. 
 
You asked the Plan to pre-approve the MRI. You say that MRI is recommended. The Plan denied your request. 
The Plan says the requested MRI is not medically necessary. 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 necessary. Our physician reviewer found the record indicates that the enrollee 
had achilles tendon pain for about one month. The record does not indicate the occurrence of acute injury or 
concerning physical examination findings. The record does not have primary source documentation of failed 
conservative therapy. 
 
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 ankle.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient stay provided from August 21, 2021, to August 
22, 2021. 
 
  You asked the Plan to pay for the inpatient stay. You say that this 1-day inpatient hospital stay is medically 
justified according to the medical records. The Plan denied your request. The Plan says criteria for inpatient 
level of care is not supported. The Plan also says that there is no documentation of persistent fluid overload not 
responsive to treatment, hemodynamic instability, persistent hypoxia or electrolyte abnormalities which would 
warrant an inpatient level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 inpatient stay. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record did not show that at the time of inpatient admission the admitting physician 
reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or 
observation care) would span two midnights. 
 
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 inpatient stay have not been met. Therefore, we decided that the Plan does 
not have to pay for the inpatient stay provided from August 21, 2021, to August 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthosis. 
 
You asked the Plan to pre-approve a MyoPro orthosis. You say that the requested MyoPro orthosis is medically 
necessary. The Plan denied your request. The Plan says the requested MyoPro orthosis 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 a MyoPro orthosis. Our reviewer says 
that the requested MyoPro orthosis is not medically necessary. Our physician reviewer found 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 enrollee's medical condition.  The studies do not indicate the 
MyoPro brace improves an individuals function or general health.  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 a MyoPro orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro orthosis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT code 99051 provided on November 21, 2021 
 
You asked the Plan to pay for CPT code 99051. You say that the medical records required to reprocess the 
claim are attached. The Plan denied your request. The Plan says bundled services are not eligible for separate 
reimbursement. 
  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 find that CPT code 99051 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99051 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of CPT code 99051 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 
99051 provided on November 21, 2021
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the emergency ambulance services (A0427-RW) provided on October 
4, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that these were ET3 ambulance services, and 
the "W" modifier is appropriate in this case. The Plan denied your request. The Plan says that modifier "W" is 
an invalid destination modifier on ambulance claims. 
 
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 find that CPT code A0427-RW is supported in the medical record. Specifically, modifier "W" is an 
appropriate destination modifier for use with ET3 ambulance claims. Based on this information, we decided 
that Medicare rules for coverage of the ambulance services have been met. Therefore, we decided that the Plan 
has to pay for the emergency ambulance services (A0427-RW) provided on October 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department visit provided on July 30, 2020. 
 
You asked the Plan to pay for emergency department visit. The Plan denied your request. The Plan says the 
Plan did not receive the primary insurance carrier's explanation of benefits. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has not received 
the primary insurance carrier's explanation of benefits. As the secondary insurer, the Plan cannot be held 
responsible for emergency department visit until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for emergency department visit provided on 
July 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for flow cytometry, first marker (88184) flow cytometry, each 
additional marker (88185) gene analysis (Janus kinase 2) variant (81270) provided on March 8, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that although you are not contracted, your 
procedures were performed at the request of an in-network physician and the specimen was directed to your 
laboratory without direct involvement from the enrollee. The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before 
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 flow cytometry, first marker (88184) flow 
cytometry, each additional marker (88185) gene analysis (Janus kinase 2) variant (81270) provided on March 
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 the computed tomography (CT) scan of the head rendered on 
November 13, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
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 the computed tomography (CT) scan of the head rendered on 
November 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gym membership purchased on November 27, 2021. 
 
You asked the Plan to pay for the gym membership. You say that you did not know you needed a confirmation 
code and prior authorization to qualify for these services. The Plan denied your request. The Plan says a 
confirmation code is required to activate and use this benefit prior to purchase. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only through the specified online vendor/coordinator. You must contact the vendor to get started with this 
benefit. 
 
The Plans rules for coverage of gym benefits have not been met because the vendor was not contacted prior to 
services and the benefit was not activated. Therefore, we decided that the Plan does not have to pay for the gym 
membership purchased on November 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the upper respiratory infection panel coded as 87486, 87496, 
87498, 87500, 87502, 87532, 87541, 87581, 87641, 87651 provided August 26, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that this test was ordered by a treating physician 
who makes the professional determination of diagnosis and medical necessity to successfully treat their patients. The Plan denied your request. The Plan says the services provided do not meet Medicare reasonable 
and necessary requirements. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Multiplex PCR respiratory viral panels of 6 or more pathogens are 
non-covered. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the upper respiratory infection 
panel coded as 87486, 87496, 87498, 87500, 87502, 87532, 87541, 87581, 87641, 87651 provided August 26, 
2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an integrated biopsychosocial assessment provided on 
November 10, 2021. 
 
You asked the Plan to pay for an integrated biopsychosocial assessment. The Plan denied your request. The 
Plan says the provider chose to opt out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
 
 
 
 
 
 The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an 
integrated biopsychosocial assessment provided on November 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a chest CT scan. 
 
You asked the Plan to pre-approve a chest CT scan. The Plan denied your request. The Plan says a chest CT 
scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a chest CT scan. Our reviewer says that 
a chest CT scan is not medically necessary. Our physician reviewer found a recent chest x-ray of  
March 30, 2022 was normal and pulmonary function tests (PFT) of April 12, 2022 were also normal. There is 
no reference via prior CT or chest x-ray report mentioning mediastinal lymphadenopathy so medical necessity 
cannot be accessed to follow via CT the alleged lymph nodes. The reasons for denial are that a chest x-ray and 
PFT study have been done and reports are in the chart. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a chest CT scan have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a chest CT scan.