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

 
We decided that the Plan does not have to pre-approve shoulder arthroplasty. 
 
You asked the Plan to pre-approve shoulder arthroplasty. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are 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 shoulder arthroplasty. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a diagnosis of right shoulder osteoarthritis. There is no supporting 
imaging studies and physical exam showing range of motion and rotator cuff pathology that cannot be repaired 
with arthroscopy surgery. Therefore, the enrollee does not meet criteria for the requested 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 shoulder arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve shoulder arthroplasty.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endovenous ablation therapy (36482) provided on July 
20, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the endovenous ablation therapy. The Plan denied your request. The Plan says 
the services were provided out-of-network and were not approved in advance. 
 
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 the endovenous ablation therapy (36482) provided 
on July 20, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the portable oxygen concentrator, (E1392). 
 
You asked the Plan to pre-approve the oxygen concentrator. You say that you are appealing the denial of a 
portable oxygen concentrator. The Plan denied your request. The Plan says the enrollee has been provided with 
oxygen equipment that meets their needs. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 oxygen concentrator Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this enrollee has COPD, and has a stationary concentrator. There is no demonstration 
that SpO2 can be maintained >91% during exercise using an oxygen conserving device at flow rate 1 to 4 
L/min. A portable oxygen concentrator is not medically necessary because Medicare criteria are not met. 
 
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 oxygen concentrator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the portable oxygen concentrator, (E1392).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the requested procedure fills a 
treatment gap for patients that do not receive adequate relief from traditional conservative methods and don't 
have instability to indicate fusion is the appropriate treatment. You say that there is sufficient science published 
in peer-reviewed publications that this procedure improves the quality of life for patients suffering from 
vertebrogenic low back pain. The Plan denied your request. The Plan says the requested procedure 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 the Intracept procedure. Our reviewer 
says that the Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is being treated for low back pain and chronic vertebrogenic pain. He 
presented with low back pain that does not radiate. The pain is aching, throbbing, and sharp, crushing, 
electrical pain. The pain is rated at 9/10. The symptoms are worsening. He is a light tobacco smoker. The exam 
reveals paraspinal muscle tenderness to palpation bilaterally. The range of motion is decreased. He has a slow and cautious gait. Detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures. In this case, there were/are multiple plausible 
pathologic sources of significant pain generation. Overall, documentation was/is lacking regarding reasonably 
detailed and/or evidenced findings supportive of the spinal vertebral bodies as being the overwhelming primary 
generators of the enrollees chronic persistent pain. Documentation does not support actual formal surgical 
ablation of pre-designated basivertebral nerves as being medically necessary and/or reasonable at this time. 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on January 14, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because lab testing related 
to treatment of end-stage renal disease (ESRD) is bundled into dialysis services and is not separately paid. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory services furnished to individuals for 
the treatment of end-stage renal disease (ESRD) are included in the ESRD prospective payment system (PPS) 
and are not paid separately.  
 
We looked at the file and Medicare rules. This lab testing was furnished for the treatment of ESRD, so payment 
for it is included in the ESRD PPS and is not separately paid. Based on this information, we decided that 
Medicare rules for coverage of lab testing have not been met. Therefore, we decided that the Plan does not have 
to pay for laboratory testing provided on January 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction services provided on November 3, 2021. 
 
You asked the Plan to pay for the services provided. You say that a doctor cannot perform surgery without 
determining the state of the cataract. The Plan denied your request. The Plan says the service is not a covered 
benefit. 
 The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The file shows that you received refraction services during a medical eye exam. The services are considered 
routine vision services. Therefore, we decided that the Plan does not have to pay for the refraction services 
provided on November 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 
You asked the Plan to pre-approve Feraheme. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Feraheme. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found you have a diagnosis of iron deficiency anemia. The documentation does not support that you have tried 
and failed Ferrlecit, Infed, or Venofer. The documentation does not support that Ferrlecit, Infed, or Venofer 
would likely be less effective and/or likely have adverse effects. Therefore, you do not meet criteria for the 
requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
December 29, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you were not treated for what you 
presented for. 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 $75 
copayment for each emergency room visit.  
 
You have been asked to pay a $75 copayment for the ER visit. The ER visit falls within the Emergency Care 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for an emergency room (ER) visit 
provided on December 29, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, emergency 
transport (A0429) and ground mileage (A0425) provided on December 2, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible 
for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice 
is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before 
rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on December 1, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the ambulance 
service, basic life support, emergency transport (A0429) and ground mileage (A0425) provided on December 
2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the receiver (monitor), dedicated, for use with 
therapeutic glucose continuous monitor system (K0554). 
 
You asked the Plan to pre-approve the therapeutic CGM. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says although the enrollee is on 3 
or more doses of insulin per day the medically necessary criteria is not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
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 therapeutic CGM. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the criteria for CGM requires that the enrollee is adjusting the doses of insulin 
according to the BG level. This does not appear to be the case from the records provided. Although the CGM 
may be helping the enrollee and may indeed be medically sound, its use does not meet the provided criteria and 
hence is not covered based o the criteria provided above. 
 
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 therapeutic CGM have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the receiver (monitor), dedicated, for use with therapeutic glucose continuous 
monitor system (K0554).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for radiology treatment from October 27, 
2021, through November 29, 2021. 
 
You asked the Plan to waive the coinsurance for radiology treatment. You say that you would like to appeal the 
cost share. The Plan denied your request. The Plan says the cost share applied 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 20% 
coinsurance for radiation received from an INN provider. The total allowed amount of the services provided is 
$6,797.92, resulting in a coinsurance amount of $1359.52. 
 
You have been asked to pay 20% coinsurance for radiology treatment. radiology treatment falls within the 
Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for radiology treatment from October 27, 2021, through November 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) guidance for needle placement 
(77012) billed for date of service January 21, 2022. 
 
You asked the Plan to pay for procedure code 77012. You say that this service was reported appropriately and 
is eligible for separate payment. The Plan denied your request. The Plan says payment for 77012 is included in 
the payment for 32408. Although 77012 was billed with a modifier to indicate separate payment for this service, the medical records do not support that this modifier was used appropriately, as the record does not 
show that 77012 was separate and distinct from 32408. 
 
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 77012 
is a column II code to column I code 32408; however, 77012 was 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 procedure code 77012. Our reviewer says that this service is 
not supported for separate payment. Our reviewer found that the operative report describes a lung biopsy under 
CT image guidance and adrenal nodule biopsy under CT image guidance. Per CPT guidelines, a core needle 
biopsy of the lung or mediastinum is most commonly performed with imaging guidance (e.g., ultrasound, 
fluoroscopy, CT). Imaging guidance codes (76942, 77002, 77012, 77021) may not be reported separately with 
32408. There is no documentation to support that these services were separate and distinct; therefore, this 
procedure cannot be reported separately, and the reported modifier is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 77012 have not been met. Therefore, we decided that the Plan 
does not have to pay for computed tomography (CT) guidance for needle placement (77012) billed for date of 
service January 21, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services billed with procedure codes 31624 and 
43246 for date of service December 13, 2021. 
 
You asked the Plan to pay for procedure codes 31624 and 43246. You say that these services were billed 
appropriately and are supported in the medical record. The Plan denied your request. The Plan says these 
services are not supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
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 procedure codes 31624 and 43246. Our reviewer says that 
the records provided do not support the services reported in this case. Our reviewer found that the submitted 
documentation does not meet the criteria to support these services as billed. The procedure report documents a 
date of service of December 14, 2021; however, these services were billed with a date of service of December 
13, 2021. In this case, the correct date of service cannot be verified, and the services cannot be verified as 
billed. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 31624 and 43246 have not been met. Therefore, we decided 
that the Plan does not have to pay for testing services billed with procedure codes 31624 and 43246 for date of 
service December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a specialist office visit provided on 
February 1, 2022. 
 
You asked the Plan to waive the deductible for a specialist office visit. You say that this was service provided 
by a doctor in the same practice group and physical office, based on a referral from the doctor you regularly 
see. The Plan denied your request. The Plan says this was correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $250 deductible for all items and services except those specifically 
excluded by the Plan contract.  
 
 
 
 
 
 
 
 
 You have been asked to pay $125.20 for a specialist office visit. A specialist office visit falls within the benefit 
category physician/practitioner services, including doctors office visits. The Plan has followed Medicare rules 
by clearly disclosing in the contract that there is a $250 deductible which applies to physician/practitioner 
services, including doctors office visits. This cost sharing is a contractual obligation that had not been met at 
the time a specialist office visit was received on February 1, 2022. Therefore, we decided that the Plan does not 
have to waive the deductible for a specialist office visit provided on February 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic testing services provided on March 7, 2022. 
 
You asked the Plan to pay for the testing services. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says the documentation does not support the study. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 In this case, the CPT Code Manual definition of code 93976 is duplex scan of arterial inflow and venous 
outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study. We find that CPT 
code 93976 is not supported in the medical record. Specifically, the records provided do not include a vascular 
study. 
 
The claim information shows that code 76705 was billed along with code 93976. In this case, we have 
confirmed that code 76705 is a column II code to column I code 93976. This claim has not been billed with an 
appropriate modifier to bypass the edit. Based on this information, we decided that Medicare rules for coverage 
of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the 
diagnostic testing services provided on March 7, 2022.