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

 
We decided that the Plan does not have to pay for venography of the arms/legs (75822-59) and venography of 
the trunk (75825-59) provided on February 22, 2022. 
 
You asked the Plan to pay for venography services. You say that the enrollee had multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between codes 75822 and 75825 and code 37238. These PTP edits both have a 
modifier indicator of 1, meaning modifiers associated with NCCI are allowed. Modifier 59 was billed to bypass 
this edit; however, the medical records do not support that these services were separate and distinct from the 
primary procedure. 
 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 codes 75822 and 75825 are both column II codes to column I code 37238; 
however, 75822 and 75825 were each billed with a modifier.  
 
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 venography services. Our reviewer says that these services 
are not supported with the modifier billed. Our reviewer found that codes 75822 and 75825 would be inclusive 
to CPT code 37238, which includes radiological supervision and interpretation. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of venography services have not been met. Therefore, we decided that the Plan 
does not have to pay for venography of the arms/legs (75822-59) and venography of the trunk (75825-59) 
provided on February 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the short-term acute care hospital can provide for all of the enrollee's present 
inpatient care needs and the health plan has stated that continued care in the short-term acute care hospital will 
be covered. Continued care in the short-term acute care hospital is appropriate until the enrollee is stable to 
transfer to 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided from March 2, 2022 to March 9, 
2022. 
 
You asked the Plan to pay for physical therapy. You say that your doctor prescribed physical therapy following 
a knee replacement surgery. You say that the doctor was specific about binging in therapy immediately before 
your first doctor appointment.  The Plan denied your request. The Plan says the out-of-network services were 
not authorized. 
 
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 physical therapy provided from March 2, 2022 to 
March 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar 
spine (72148). 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that the enrollee needs a new updated 
MRI before the pain management clinic will see her. The Plan denied your request. The Plan says the enrollee 
does not meet the criteria for coverage. 
 
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 an MRI of the lumbar spine. Our 
reviewer says that an MRI of the lumbar spine is not reasonable and necessary. Our physician reviewer found 
the enrollee needs a new updated MRI before she can be seen in the pain management clinic. The enrollee was 
seen by her primary care physician on June 2, 2022. She reported trying to take Gabapentin two nights in a 
row, but it made her pain worse. Our reviewer found that the physical exam notes decreased range of motion in 
the spine as well as with pain. The provider did prescribe Lyrica and Tramadol for the enrollee's pain. There is 
no specific clinical rationale for the requested MRI. 
 
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 MRI of the lumbar spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a Veriflex device (22869, 22870). 
 
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 not supported. 
 
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 the Vertiflex device is experimental. More research is needed to show it is safe 
and effective. 
 
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, 22870).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Magnetic resonance imaging (MRI) on 
January 10, 2022. 
 
You asked the Plan to waive the copayment for MRI. You say that you were told that there was no copay. The 
Plan denied your request. The Plan says the cost-sharing you are being charged is 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 a $150 
copayment for MRI. Other outpatient diagnostic tests: Magnetic resonance imaging (MRI), computed 
tomography (CT), and positron emission tomography (PET).  
 
You have been asked to pay a $150 copayment for MRI. MRI falls within the Outpatient diagnostic test and 
therapeutic service 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 
Magnetic resonance imaging (MRI) on January 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a biopsy to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the biopsy. You say that you have been receiving care from this provider for 
the last six years and you don't see any reason to have to start all over with a new provider. The Plan denied 
your request. The Plan says services are denied because the provider is not a preferred network 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a biopsy to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexcom continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve Dexcom CGM. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested item. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, or have had an in-person visit with 
their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of Dexcom CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Dexcom continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthoses provided on April 19, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed 
service cannot be verified. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the orthoses provided on April 19, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an epidural steroid injection from an OON provider. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the Plan is choosing to put a 
compromised woman on a plane in the time of highly contagious illnesses. You say that this is not caring for 
your well-being, and you are appealing the denial. The Plan denied your request. The Plan says in-network 
providers are available. 
 
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is 
considered accessible to an enrollee if contract providers are available within reasonable distance and travel 
time from the enrollees home. The Plan says that enrollees must use contract providers.  
 
The provider is a non-contract provider. We were able to confirm the in-network provider the Plan approved is 
not located within reasonable distance and travel time from your home. Under Medicare rules, this means that 
contract providers are not accessible to you. Therefore, we decided that the Plan has to pre-approve an epidural 
steroid injection from an OON provider.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abdominal binder. 
 
You asked the Plan to pre-approve an abdominal binder. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
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 an abdominal binder.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic services FoundationOne CDx (F1CDx) test (0037U) 
provided January 19, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that all necessary information to validate the 
medical necessity for testing has been met and is included in the accompanying documentation. The Plan 
denied your request. The Plan says the services are not medically necessary services rendered do not meet the 
coverage requirements outlined in the NCD. 
 
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 pay for the laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is inadequate documentation that the FoundationOne CDx (F1CDx) test 
(0037U) provided on 01/19/2022 meets Medicare criteria for coverage. Provided records do not clearly 
document that the enrollee has either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV 
cancer; and has not been previously tested with the same test using NGS for the same cancer genetic content 
and has decided to seek further cancer treatment (e.g., therapeutic chemotherapy). 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for genetic services FoundationOne CDx (F1CDx) test (0037U) provided January 19, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ophthalmological services: medical 
examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient 
(92004) provided February 16, 2022. 
 
You asked the Plan to waive the copayment for the medical eye exam. You say that you would not have gone 
for the eye exam if you had known your subsequent services would not be covered. The Plan denied your 
request. The Plan says the copayment was 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 $40 
copayment for each Medicare-covered vision exam. 
 
 
 
 
 You have been asked to pay a $40 copayment for the medical eye exam. The medical eye exam falls within the 
Vision 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 the ophthalmological 
services: medical examination and evaluation with initiation of diagnostic and treatment program; 
comprehensive, new patient (92004) provided February 16, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 9, 2022, to 
February 20, 2022. 
 
You asked the Plan to pay for the home health services. You say that the enrollee was placed on hospice care. 
You also say that their policy states that this is 24/7 care covered with the doctor's orders. The Plan denied your 
request. The Plan says the claim processed correctly. 
 
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 home health services provided from February 9, 2022, to 
February 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for office visit on February 15, 2022, to 
February 22, 2022 
 
You asked the Plan to waive the copayments for office visit. You say that the enrollee developed a bed sore due 
to the negligence of the rehabilitation facility and should not be responsible for the expenses. The Plan denied 
your request. The Plan says the cost-sharing the enrollee is charged is 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $40 copayment for each specialist visit for Medicare-covered services. Covered services include: 
Medically necessary medical care or surgery services furnished in a physicians office, certified ambulatory 
surgical center, hospital outpatient department, or any other location. Consultation, diagnosis, and treatment by 
a specialist. There were 2 visits, resulting in a total copayment amount of $80.  
 
 
 
 The enrollee has been asked to pay a $40 copayment for office visit. Office visit falls within the 
Physician/Practitioner services, including doctor's office visits benefit category. This means that the enrollee 
has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayments for office visit on February 15, 2022, to February 22, 2022
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (95885, 95999, 95907) provided on December 1, 
2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not supported. 
 
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 95885 is "Needle electromyography, each extremity, with 
related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; 
limited (List separately in addition to code for primary procedure)". The CPT Code Manual definition of code 
95999 is "Unlisted neurological or neuromuscular diagnostic procedure". The CPT Code Manual definition of 
code 95907 is "Nerve conduction studies; 1-2 studies". 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use of codes 95885, 
95999, and 95907 is not supported by the records provided. Our reviewer found that for CPT 95885, nerve 
conduction studies cannot be verified, and therefore this procedure would not be covered. For CPT 95999, the 
procedure report does not include documentation of an unlisted procedure code. Therefore, this procedure 
cannot be verified. For CPT 95907, the procedure report describes "pedicle screw stimulation". It is 
inappropriate to report nerve conduction studies (measures amplitude and latency/velocity) for the documented 
procedure. Therefore, this procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (95885, 95999, 95907) provided on December 1, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76700) provided on October 27, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the ultrasound. You say that the nursing home where the enrollee resides has an 
exclusive contract with this provider. The Plan denied your request. The Plan says authorization was not 
obtained before the services were rendered to the enrollee. 
 
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 abdominal ultrasound (76700) provided on October 27, 2021 
by an out-of-network (OON) provider.