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

 
We decided that the Plan does not have to pay for procedure code 64483 billed for date of service February 22, 
2022. 
 
You asked the Plan to pay for procedure code 64483. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
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 64483 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 
procedure code 64483 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 64483 billed for date of service February 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494). 
 
You asked the Plan to pre-approve the injections. You say that the enrollee would like to avoid opiates, as well 
as non-steroidal anti-inflammatory drugs (NSAIDS) due to their GERD. The Plan denied your request. The 
Plan says the requested injections are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that after the first diagnostic facet joint procedure, there 
must be a consistent positive response of at least 80% relief of primary (index) pain for a second facet joint 
procedure to be considered 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 injections. Our reviewer says that 
the injections are not medically necessary. Our physician reviewer found the provided documentation does not 
indicate that the enrollee experienced 80% relief from the initial facet joint injections. Therefore, the reviewer 
found that the requested injections are 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 the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections (64493, 64494).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic hearing exam provided on June 
18, 2022. 
 
You asked the Plan to waive the copayment for diagnostic hearing exam. You say that you already paid for 
this. The Plan denied your request. The Plan says this cost sharing was charged 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 $45 
copayment for Hearing services. 
 
You have been asked to pay a $45 copayment for diagnostic hearing exam. This item/service falls within the 
Hearing 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.You have been asked to pay $31 copayment which is less than the standard $45 copayment for 
diagnostic hearing exams. Therefore, we decided that the Plan does not have to waive the copayment for 
diagnostic hearing exam provided on June 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided on April 7, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that authorization was not able 
to be obtained prior to the services being rendered. The Plan denied your request. The Plan says prior 
authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the office visit (99213) provided on April 7, 2022, by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic shoes and inserts. 
 
You asked the Plan to pre-approve these services. You say that you are allowed two pairs of shoes and six 
custom inserts per year. The Plan denied your request. The Plan says you have exhausted the benefit limit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan contract covers one pair of custom-molded 
shoes and two extra pairs of inserts each calendar year or one pair of depth shoes and three pairs of inserts each 
year.   
 
We looked at the file, the Plans rules, and Medicare rules. The file shows that you received one pair of diabetic 
shoes and three pairs of custom inserts on September 16, 2022. Further orthotics are not covered by the Plan or 
Medicare. Therefore, we decided that the Plan does not have to pre-approve diabetic shoes and inserts.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient psychiatric stay provided from December 18, 2020, to 
January 25, 2021. 
 
You asked the Plan to pay for the inpatient psychiatric stay. You say that this claim continues to deny in error. 
You also say that you would like payment to be issued for the authorized days. The Plan denied your request. 
The Plan says that this claim was filed beyond the applicable timely filing limit. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not substantiated their denial as they have incorrectly applied the 
timely filing rule. Specifically, the record shows that the initial claim submission was filed on January 19, 
2022, which is less than one year past the date the enrollee was discharged. The Plan also has not provided a 
claim for the services rendered. Therefore, we decided that the Plan has to pay for the inpatient psychiatric stay 
provided from December 18, 2020, to January 25, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the x-rays of the cervical spine provided 
on July 21, 2022. 
 
You asked the Plan to reduce the copayment for the x-rays of the cervical spine. You say that you do not know 
why you were charged $100 instead of $5. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $100 
copayment for basic radiological services at an outpatient hospital. 
 
You have been asked to pay a $100 copayment for the x-rays of the cervical spine. This item/service falls 
within the basic radiological services at an outpatient hospital 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 the x-rays of the cervical spine provided on July 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp (E1399). 
 
You asked the Plan to pre-approve the wheelchair ramp. You say that the wheelchair ramp is medically 
necessary. The Plan denied your request. The Plan says this item is non-covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair ramp (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on September 11, 
2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that you were informed that follow-up 
visits were covered. The Plan denied your request. The Plan says this cost sharing was charged 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 $45 
copayment for physician/practitioner services, including doctors office visits (specialist). 
 
You have been asked to pay a $45 copayment for the office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits (specialist) benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the office visit provided on September 11, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ophthalmologist visit with a non-contracted tertiary 
provider. 
 You asked the Plan to pre-approve an ophthalmologist visit. You say that you struggle with vision, and would 
like to see a new ophthalmologist. The Plan denied your request. The Plan says you do not meet Tertiary Care 
guidelines. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 ophthalmologist visit. Our physician 
reviewer found out-of-network services are not medically supported. Our reviewer also found that your 
condition of nasolacrimal duct obstruction can be treated by multiple in-network Ophthalmologists.  
 
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 ophthalmologist visit have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an ophthalmologist visit with a non-contracted tertiary provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and related accessories 
provided on October 27, 2021. 
 
You asked the Plan to pay for the pneumatic compression device and related accessories. You say that these 
items were medically necessary and should be paid. The Plan denied your request. The Plan says this item is 
not covered because it is included in the cost for the facility. 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the pneumatic compression device and related accessories was used in a SNF or hospital. In 
addition, Medicare rules explicitly state that pneumatic compression devices used for prevention of deep vein 
thrombosis (i.e., coded as E0676) are not covered.  The device you provided was for prevention of deep vein 
thrombosis and was coded as E0676. Therefore, we decided that the Plan does not have to pay for the 
pneumatic compression device and related accessories provided on October 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient behavioral health services. 
 
You asked the Plan to pre-approve inpatient behavioral health services. You say that the enrollee is currently 
admitted as a psychiatric patient, and continues to be medically necessary based on paranoia. The Plan denied 
your request. The Plan says there is no additional information provided that supports overturning the original 
denial. The Plan also says there was no evidence provided that enrollee's treatment needs cannot be met at less 
restrictive, outpatient services. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient behavioral health services. 
Our reviewer says that the enrollee does not meet the Medicare criteria for inpatient psychiatric care. Our 
physician reviewer found that it is not expected that the enrollee will improve in a reasonable period of time 
beyond the date in question as the enrollee was not showing any dangerousness to self or others, auditory or 
visual hallucinations, or aggressive behaviors. It does not appear medically necessary and reasonable to have 
psychiatric care provided at the acute inpatient level of care rather than a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient behavioral health services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient behavioral health services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Toric or multifocal correcting intraocular lens (IOL) 
(A9270) in lieu of conventional IOLs following cataract surgery. 
 
You asked the Plan to pre-approve a Toric. You say that you were advised that if you went with standard lenses 
that you would need them all the time, and if you got upgraded lenses you would not need glasses, but there are 
multiple disclaimers involved and it cannot guarantee if glasses will or will not be needed. You also say that 
the impression is that the upgrade will free you from the restriction of eyewear. The Plan denied your request. 
The Plan says the service that you have requested is not a covered benefit under Original Medicare and is not 
included in the Plan's Medical Benefits Chart. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
A Toric is an A-C IOL, and while an A-C IOL may be appropriate for you, neither the Plan nor Medicare 
covers the astigmatism-correcting feature of an IOL. Therefore, we decided that the Plan does not have to pre-
approve a Toric or multifocal correcting intraocular lens (IOL) (A9270) in lieu of conventional IOLs 
following cataract surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667).  
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation of swelling in the trunk or abdomen. 
 
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 the provided records do not document that the enrollee has lymphedema of the chest, trunk, or 
abdomen. It cannot be said that the enrollee has unique characteristics that would indicate the segmented pump 
over a standard pump.  
 
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 a pneumatic compression device (E0652, E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve negative pressure wound therapy (NPWT). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the request exceeds the time limit. 
 
The Plan must follow Medicare rules. The rules state that NPWT and supplies is denied as not medically 
necessary when 4 months have elapsed. 
 
We looked at the file and Medicare rules. The file shows that the enrollee has used the NPWT for four months. 
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 negative pressure wound therapy (NPWT).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99204 billed for date of service July 29, 
2022. 
 
You asked the Plan to pay for procedure code 99204. The Plan denied your request. The Plan says payment for 
code 99204 is bundled into payment for code 96372.  
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 99204 
is a column II code to column I code 96372. 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 99204 billed for date of service July 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service April 7, 
2022. 
 
You asked the Plan to pay for procedure code 93042. The Plan denied your request. The Plan says payment for 
code 93042 is bundled into payment for code 99291. 
 
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 93042 
is a column II code to column I code 99291 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 93042 billed for date of service April 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81455). 
 
You asked the Plan to pre-approve genetic testing. You say that the most efficient and cost-effective way to 
confirm drugable targets in this tumor is by performing a comprehensive mutation panel. Results from the test 
will provide diagnostic and prognostic information that will have a direct impact on the enrollee's treatment and 
management. The Plan denied your request. The Plan says the requested testing is not medically necessary 
because this test is not an FDA approved companion diagnostic nor certified by a third-party consistent with 
the New York State Department of Healths Clinical Laboratory Evaluation Program (CLEP) review standards. 
 
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. The LCD confirms that NGS testing for patients with advanced 
cancer is reasonable and necessary only when performed in a CLIA-certified laboratory. The records show you 
requested a test to be performed at a facility that does not have New York State CLEP certification, therefore, 
the test does not meet coverage criteria. Based on this information, we decided that Medicare rules for coverage 
of genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic 
testing (81455).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) 
(G0299) and direct skilled nursing services of a licensed practical nurse (LPN) (G0300) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the direct skilled nursing services of an RN and LPN. The Plan denied your 
request. The Plan says the requested provider is OON. The Plan also says OON services are not approved when 
they are available within the Plan's 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 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. 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 direct skilled nursing services of a registered nurse (RN) (G0299) and direct skilled nursing services of 
a licensed practical nurse (LPN) (G0300) to be provided by an out-of-network (OON) provider.