Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the left shoulder for the 
enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there has not been six weeks of provider-directed treatment. 
 
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 medically reasonable and necessary. Our physician reviewer found that the x-rays revealed 
significant degenerative changes of the glenohumeral joint. Positive Neer and Hawkins tests indicate likely 
rotator cuff disease. Due to these positive physical findings, and the degenerative changes of the glenohumeral 
joint, the requested MRI of the left shoulder is 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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of the left shoulder for the enrollee.  
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical services (procedure code 35703) provided to the enrollee on 
July 14, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the records do not support the services billed. 
 
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 35703 is "Exploration not followed by surgical repair, artery; lower extremity (eg, common femoral, deep 
femoral, superficial femoral, popliteal, tibial, peroneal)." 
 
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 services at issue in 
this case were supported by the medical records. Our reviewer found that the operative note states in order to 
mobilize the adipofascial flap, dissection of the femoral vessels were required. The femoral vessels were 
carefully dissected and retracted into the medial aspect of the wound in order to mobilize the medial and lateral 
leg tissues. The vessels were carefully dissected and protected throughout this dissection and transposition. 
Therefore, the records do support that CPT 35703- exploration not followed by surgical repair, artery; lower 
extremity (e.g., common femoral, deep femoral, superficial femoral, popliteal, tibial, peroneal)- was rendered 
in this case. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
surgical services (procedure code 35703) provided to the enrollee on July 14, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on November 4, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the provider must see all patients in 
the nursing home that need care. You also say that the provider has no option to determine which patient he 
wants to perform services on. The Plan denied your request. The Plan says this provider is not a network 
provider with the Plan, and the services were not referred by a network provider or rendered in an in-network 
facility. The Plan also says that they have also determined that these services are not urgent or emergent, nor 
were they 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 a domiciliary or rest home visit provided on 
November 4, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit and debridement of nail(s) 
provided on April 1, 2022, by an OON provider. 
 
You asked the Plan to pay for the domiciliary or rest home visit and debridement of nail(s). You say that you 
are requesting reconsideration to reprocess the claim for payment. 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 a domiciliary or rest home visit and debridement 
of nail(s) provided on April 1, 2022, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on April 7, 2022. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says your benefit for 
the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 5, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
April 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services for lower intestinal endoscopic 
procedures provided on April 8, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for anesthesia services for lower intestinal endoscopic procedures. You say that this 
provider regularly complies with all administrative requirements for payments. The Plan denied your request. 
The Plan says the services were rendered and referred by all non-participating providers. The Plan also says 
that they have also determined that these services are not urgent or emergent, nor were they 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 anesthesia services for lower intestinal endoscopic 
procedures provided on April 8, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 5, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service and the attached reports support the level of service. You say that the claim should be reconsidered 
for processing. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment 
for code 70496.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthrocentesis provided on April 28, 2022, by an OON 
provider. 
 
You asked the Plan to pay for arthrocentesis. You say to please review the documents submitted to support the 
reconsideration request of the denied claim. 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 arthrocentesis provided on April 28, 2022, by an 
OON provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services provided to the 
enrollee from March 2, 2022, to March 31, 2022. 
 You asked the Plan to pre-approve the services. You say that this was medically necessary. The Plan denied 
your request. The Plan says there was no daily skilled nurse or therapist need. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found that 
there were no identifiable skilled nursing service needs. The enrollee did not require skilled nursing or therapy 
services on a daily basis. The enrollee did not meet severity of illness or intensity of service criteria for an 
inpatient basis in a skilled nursing facility setting. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services provided to the enrollee from March 2, 2022, to 
March 31, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the behavioral health visits to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the behavioral health visits. You say that you have been seeing this provider 
for years and you trust the provider. The Plan denied your request. The Plan says the requested provider is an 
OON provider and there are multiple in-network providers that can provide the same quality of service. Also, 
the requested provider is non-Medicare certified. 
 
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 and is not Medicare certified. 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 the behavioral health visits to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 9, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the over the counter (OTC) COVID-19 tests purchased on 
April 19, 2022. 
 
You asked the Plan to pay for the COVID-19 tests. You say that you were told by a doctor to go to the drug 
store, purchase the tests, and save the receipts so you could be reimbursed. The Plan denied your request. The 
Plan says the COVID-19 tests you purchased are considered OTC items. The Plan also says that as of April 4, 
2022, OTC COVID-19 tests are covered by Original Medicare only, not by your insurance plan. 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the 
COVID-19 tests is an OTC item. The Plan does not offer a supplemental benefit covering this service, as this is 
not currently required by Medicare. However, for future purchases, these can be obtained with participating 
providers and covered by Original Medicare when using your Medicare card rather than your Plan card. 
Neither Medicare nor your Plan currently offers reimbursement of purchased COVID-19 tests. Therefore, we 
decided that the Plan does not have to pay for the over the counter (OTC) COVID-19 tests purchased on April 
19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) of the abdomen and pelvis 
(74176) provided on March 11, 2021. 
 
You asked the Plan to pay for the CT scan. You say that you would like this claim to be reprocessed for 
payment. The Plan denied your request. The Plan says Medicare denies a claim for untimely filing if the receipt 
date applied to the claim exceeds 12 months or 1 calendar year from the date the services were furnished. The 
Plan also says that the claim was received on March 21, 2022, which is past the allowed 12-month timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the CT scan was not filed until March 21, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the computed tomography (CT) of the abdomen and pelvis (74176) provided on 
March 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 28, 2022, billed 
with code 81479 
 
You asked the Plan to pay for code 81479. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the genetic testing provided on 
February 28, 2022, billed with code 81479 have been met. Specifically, there is no documentation supporting 
that the services described by this single code are distinct from the services that were reimbursed by the Plan on 
a prior claim. Without clear documentation showing that code 81479 refers to a service that has not already 
been reimbursed, coverage for this code cannot be confirmed. Therefore, we decided that the Plan does not 
have to pay for the genetic testing provided on February 28, 2022, billed with code 81479
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulation or waive the coinsurance for 
chiropractic manipulative treatment provided on April 6, 2022. 
 
You asked the Plan to pay for electrical stimulation and to waive the coinsurance for chiropractic manipulative 
treatment. You say that these healing techniques were critical for your healing process. The Plan denied your 
request. The Plan says other services performed by a chiropractor are not covered. The Plan also says that the 
coinsurance for the chiropractic manipulative treatment 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 Medicare-covered 
chiropractic services received out-of-network are responsible for 50% coinsurance at a specialists office. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
You have been asked to pay $19.51 (coinsurance) for the chiropractic manipulative treatment received out-of-
network. The chiropractic manipulative treatment falls within the Chiropractic 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. 
 
The records show that the service at issue is electrical stimulation and not manual manipulation of the spine. 
Therefore, we decided that the Plan does not have to pay for electrical stimulation provided on April 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed. 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that you disagree with the Plan's 
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. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
2. Requires attachments which can only be attached to a hospital bed; AND 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a semi-electric hospital bed. Our 
reviewer says that the documentation does not support that the requested item is medically reasonable or 
necessary. Our physician reviewer found the enrollee does have a diagnosis of congestive heart failure, but it is 
noted to be stable, and the enrollee does not require the head of bed to be elevated greater than 30 degrees. The 
documentation shows that the requested semi-electric hospital bed is being requested because the enrollee is 
bedridden and requires dental work to be performed at home under anesthesia. Additionally, there is no 
indication that the enrollee requires frequent re-positioning for a specific medical condition. Therefore, the 
enrollee does not meet criteria for the requested item. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed.