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

 
We decided that the Plan does not have to pay for the injection services provided on October 12, 2021. 
 
You asked the Plan to pay for the services provided. You say that the records support the frequency. The Plan 
denied your request. The Plan says Medicare rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 20526 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. 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 the injection services 
provided on October 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus vaccine (90714) and administration fee (90471) 
provided on August 27, 2021. 
 
You asked the Plan to pay for the vaccine services. You say that you believe that this should be covered. The 
Plan denied your request. The Plan says as this service was not related to an accidental puncture wound or 
injury and was preventative in nature, it is not covered under the medical benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine services. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine 
services. Therefore, we decided that the Plan does not have to pay for the tetanus vaccine (90714) and 
administration fee (90471) provided on August 27, 2021.  
 
Benefits for the vaccine services may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and 
management of a new patient (99326) and the transitional care management services (99495) rendered by the 
out-of-network (OON) provider on October 27, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of a new 
patient (99326) and the transitional care management services (99495) rendered by the out-of-network (OON) 
provider on October 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve self-administered drugs provided from June 24, 2021, to 
June 29, 2021. 
 
You asked the Plan to pre-approve self-administered drugs. You say that you had to go to the hospital you were 
taken to and had no say. The Plan denied your request. The Plan says the denial of payment for these drugs is 
correct, because self-administered drugs are not covered by Medicare Part B. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs.  
 
The self-administered drugs requested here are not among the types which are covered by Medicare Part B. 
Therefore, we decided that the Plan does not have to pre-approve self-administered drugs provided from June 
24, 2021, to June 29, 2021.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional chest x-ray provided to the enrollee on August 
20, 2021. 
 
You asked the Plan to pay for the x-ray. You say that this should be paid for. The Plan denied your request. The 
Plan says there needs to be records to substantiate the need for the additional test. 
 
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 71045 is "Radiological examination, chest." 
 
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 x-ray. Our reviewer says that the services at issue in this 
case were not supported by the medical records. Our reviewer found there is a report of a single chest x-ray on 
8/20/21 and this was following endotracheal tube placement. No separate dictation of a second film is in the 
records. A review of the procedure note of the catheter placement there is no mention of a post procedure chest 
film to document catheter location. A chest film at the conclusion of this procedure is considered by CMS to be 
covered under the procedure itself but such a film was not documented. In summary, reimbursement for the 
post endotracheal tube placement film is appropriate and has already been paid. 
 
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 x-ray have not been met. Therefore, we decided that the Plan does not have 
to pay for an additional chest x-ray provided to the enrollee on August 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services rendered from April 19, 2021 
to May 3, 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 submitted records do not support the billing of diagnosis codes A41.9 and J18.9. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis A41.9 (sepsis, unspecified 
organism) and secondary diagnosis J18.9 (pneumonia, unspecified organism). 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 these services. Our reviewer says that the submitted records do not support the 
billing of diagnosis codes A41.9 and J18.9. Our physician reviewer found the enrollee was admitted to the 
hospital with a listed primary diagnosis of sepsis and secondary diagnosis pneumonia. The evidence presented 
showed that the enrollee had pneumonia, but there was insufficient evidence of sepsis being present based on 
current criteria for such a definition. There was insufficient evidence of organ dysfunction related to the 
infection nor was there sufficient evidence of a dysregulated immune-mediated response to the infection to 
meet the criteria. Therefore, the sepsis diagnosis is not supported, and pneumonia should be primary diagnosis 
for this admission based on the provided documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services rendered from April 19, 2021 to May 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 26, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prostatic artery embolization (PAE) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this procedure is necessary for the enrollee. The 
Plan denied your request. The Plan says that there are no studies to show PAE is of better benefit than more 
established surgical intervention. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Prostatic arterial 
embolization (PAE) is considered an experimental technique to treat symptomatic Benign Prostatic 
Hyperplasia (BPH). Very limited studies have demonstrated possible short-term safety and efficacy.  
 The most recent AUA guidelines do not recommend this procedure outside of a clinical trial setting. Our 
physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prostatic artery embolization (PAE) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Percutaneous implantation of neurostimulator electrode 
array, epidural (63650) and Implantable neurostimulator electrode (L8680) for the enrollee. 
 You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there are other options that have yet to be tried. 
 
The Plan must follow Medicare rules. Medicare rules say that electrical nerve stimulators can be covered if 
Medicare criteria has been 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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Not all treatment 
options have been tried. The stimulator is not indicated at this time. Our physician reviewer found that the 
enrollee's condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Percutaneous implantation of neurostimulator electrode array, epidural (63650) and 
Implantable neurostimulator electrode (L8680) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 20, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 20, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation. 
 
You asked the Plan to pre-approve additional mileage. You say that the orthopedic surgeon that you see has 
been treating your back pain for 10 years. You also say that you cannot drive. The Plan denied your request. 
The Plan says additional mileage beyond the allowed 50 miles is not covered. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when trips within 50 miles of the pick up location.   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the file shows that 
you are requesting transportation 38 miles beyond the 50 mile limit. The Evidence of Coverage clearly states 
that you are responsible for any costs over the trip limit. Therefore, we decided that the Plan does not have to 
pre-approve additional mileage for routine transportation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional reimbursement for the COVID-19 testing 
provided on October 15, 2021. 
 
You asked the Plan to provide additional reimbursement for the COVID-19 testing. You say that you do not 
understand why the Plan reimbursed the total amount paid for your spouse's testing but only $51 for your test. 
You feel that you should be reimbursed the total amount which you paid up front. The Plan denied your 
request. The Plan says this was reimbursed based on the Medicare allowable for this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that noncontract providers enrolled in Medicare must 
accept Medicare allowable as payment in full for covered services. This imposes a cap on the amount Plans 
must pay to a noncontract provider for these services.  
 
In this case, your Plan correctly reimbursed the total Medicare allowed amount for a COVID-19 test. Although 
the lab asked you to pay more than the Medicare allowable, the Plan cannot be obligated to pay more than this 
amount. Therefore, we decided that the Plan does not have to provide additional reimbursement for the 
COVID-19 testing provided on October 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine 
for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that you would like this covered as there has been 
provided-directed treatment for at least six weeks. The Plan denied your request. The Plan says the notes do not 
show an examination of the spine. 
 
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 requesting 
physician states that the enrollee has had a six week trial of physical therapy, but the records do not include 
physical therapy evaluation, documentation or follow-up notes by the referring clinician. Without such 
documentation the medical necessity of MRI of the lumbar spine 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 lumbar spine for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Inogen portable oxygen concentrator (E1390), provided 
on September 21, 2021. 
 
You asked the Plan to pay for the Inogen portable oxygen concentrator. You say that you want a backup for 
your oxygen tank in case power goes out. The Plan denied your request. The Plan says this is duplicate 
equipment as you are currently renting stationary and portable oxygen from our Medicare participating DME 
vendor and purchased oxygen equipment is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. Additionally, Medicare rules say that only rented oxygen equipment is eligible for coverage and purchased oxygen equipment is statutorily non-covered. 
 
The file shows that you had stationary and portable oxygen at the time the Inogen portable oxygen concentrator 
was received. This item serves the same purpose as the Inogen portable oxygen concentrator. Also, Medicare 
rules say that only rented oxygen equipment is eligible for coverage and purchased oxygen equipment is 
statutorily non-covered. Therefore, we decided that the Plan does not have to pay for the Inogen portable 
oxygen concentrator (E1390), provided on September 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the primary care office visits you had on 
March 25, 2021, June 3, 2021, and October 29, 2021. 
 
You asked the Plan to waive the copayments for the primary care office visits. You say that these copayments 
should be waived because you went into the office to be treated for pain and redness in your arm from your 
COVID-19 vaccinations. The Plan denied your request. The Plan says you were charged these copayments 
correctly. Because these visits were not for the treatment or diagnosis of COVID-19 itself, the copayments 
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 $5 
copayment for primary care office visits.  
 You have been asked to pay a $5 copayment for the primary care office visits. There was no copayment waiver 
in place regarding treatment for reactions to the COVID-19 vaccine. 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 
copayments for the primary care office visits you had on March 25, 2021, June 3, 2021, and October 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nurtec ODT for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nurtec ODT for the 
enrollee.  
 
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 1, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on September 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says this service is not a covered benefit. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered an experimental/ investigational procedure. Therefore, the request 
is considered not medically reasonable or 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 an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.