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

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says the reason this request for daily picture studies cannot be approved is because only 
weekly pictures studies are needed. 
 
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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the treatment itself is not disputed in this case but rather the need for image guidance. IGRT is a 
means to improve set-up accuracy. IGRT uses daily image guidance to help localize the target so as to 
minimize normal tissue dosing. Specifically, IGRT allows accuracy of treatment delivery, so when generating a 
planning target margin, the margins can be reduced, and thus allow reduction in the volume of normal tissues 
exposed to radiation. Usually, IGRT is used when critical structures are abutting or in close proximity to the 
target that is being treated to high doses. This situation does not apply to this patient for which the target lesion 
can be seen on the skin to assist in daily set up. When treating skin cancers, there is generally not a need for IGRT unless deep structures are being treated. The case file includes ultrasound (US) images (presumably from 
this patients case  though not specified in the file). The notes indicate a decision to hold treatment. Generally 
this decision can be made simply by examining the skin. Holding treatment based on US findings is not 
evidence-based. Certainly using ultrasound on a daily basis is not unreasonable to offer but not necessary. 
Therefore to bill for daily simple simulations and/or IGRT for a technology for which need has not been 
established by published data or supported by consensus guidelines (many of which recommend against 
treatment with these devices in general- citations below) is not necessary. This request would not be furnished 
in accordance with accepted standards of medical practice. 
 
 
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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve image-guided radiation therapy (IGRT).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for code 23472 provided at an ambulatory surgical center (ASC) on April 
25, 2022. 
 
You asked the Plan to pay for code 23472. You say that if this code is not payable in an ASC, then the Plan 
should never have authorized it. The Plan denied your request. The Plan says that this code is not payable when 
performed in an ASC. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
In this case, the Plan explicitly authorized code 23472 to be performed in an ASC.  In fact, the authorization 
(dated April 8, 2022) clearly states that this service is approved at an ASC.  The Plan made the decision that 
this is a covered service when they issued this authorization.  It is not appropriate for the Plan to deny this code 
after the fact when the error was the Plan's in issuing this authorization in the first place. We agree that this 
code is not typically payable by Medicare when performed in an ASC.  It underscores that the Plan should 
never have issued this authorization if they did not intend to cover this service as it was approved. You 
reasonably relied on the Plans authorization to ensure coverage of this service. Therefore, we decided that the 
Plan has to pay for code 23472 provided at an ambulatory surgical center (ASC) on April 25, 2022.  
 
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 pay for an x-ray (71045) provided on December 31, 2021. 
 
You asked the Plan to pay for an x-ray. You say that the enrollee had multiple exams. The Plan denied your 
request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on January 19, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for an x-ray have not been met. Therefore, we 
decided that the Plan does not have to pay for an x-ray (71045) provided on December 31, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for surgical debridement (11042) and a 
duplex scan (93926) provided from April 22, 2022, to May 6, 2022. 
 
You asked the Plan to waive the cost-sharing for surgical debridement and a duplex scan. You say that this 
should not be considered surgery. 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 $250 
copayment for outpatient surgery services and a 5% coinsurance for Medicare-covered radiological diagnostic 
services. 
 
You have been asked to pay a $250 copayment for each of three surgical debridement services and a 5% coinsurance for a duplex scan. Surgical debridement falls into the outpatient surgery benefit category, and a 
duplex scan falls into the Medicare-covered radiological diagnostic 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 cost-sharing for surgical debridement (11042) and a duplex scan (93926) provided 
from April 22, 2022, to May 6, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance responses and treatment, no transport (A0998) 
and ground mileage (A0425) provided on July 21, 2022. 
 
You asked the Plan to pay for the ambulance responses. You say that the paramedic services were medically 
necessary. The Plan denied your request. The Plan says ambulance services are not covered when there is no 
transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.   
The ambulance company did not provide transport services on July 21, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance responses and treatment, 
no transport (A0998) and ground mileage (A0425) provided on July 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for surgery services provided on July 12, 2022. 
 
You asked the Plan to waive the copayment for surgery services. You say that you would like to appeal the 
copayment 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 $300 
copayment for in-network outpatient surgery.  
 
You have been asked to pay a $300 copayment for surgery services. This item/service falls within the in-
network outpatient surgery 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 surgery 
services provided on July 12, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for ophthalmic imaging and an ophthalmic 
ultrasound provided on June 24, 2022. 
 
You asked the Plan to waive the copayments for ophthalmic imaging and an ophthalmic ultrasound. You say 
that this should be 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 $10 
copayment for Medicare-covered outpatient diagnostic tests and $100 for Medicare covered ultrasounds.  
You have been asked to pay $10 copayment for ophthalmic imaging and $11.43 for the ophthalmic ultrasound 
which is less than the standard $100 copayment. This item/service falls within the Medicare-covered outpatient 
diagnostic tests 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 copayments for ophthalmic imaging and 
an ophthalmic ultrasound provided on June 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need better care than what the skilled nursing 
facility can offer. You say that you need to learn how to manage walking with a fused ankle in a safe manner 
also having dementia you need time to learn new safety measures while allowing them to sink in. The Plan 
denied your request. The Plan says an IRF admission is not medically necessary, and you can receive the care 
you need in another setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on October 
24, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you were told that your 
copayment is $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 $40 
copayment for a covered specialist office visit. 
 
You have been asked to pay a $40 copayment for a specialist office visit. This item/service falls within the a 
covered specialist office visit 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 a specialist 
office visit provided on October 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS HF system. 
 
You asked the Plan to pre-approve a CardioMEMS HF system. You say that the requested CardioMEMS HF 
system is medically necessary. The Plan denied your request. The Plan says the requested CardioMEMS HF 
system 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 a CardioMEMS HF system. Our 
reviewer says that the requested CardioMEMS HF system is not medically necessary. Our physician reviewer 
found the CardioMEMS device was approved by the Food and Drug Administration (FDA) in 2014 and 
consists of a sensor device placed in the pulmonary artery to allow measurement of pulmonary artery pressure 
in the management of patients with congestive heart failure (CHF). The clinical study on which FDA approval 
was based showed improved clinical outcomes and decreased hospitalizations in patients in whom the 
CardioMEMS system was implanted, reflecting a patient population with preserved ejection fraction and was 
somewhat limited in scope. Subsequent follow-up studies remain encouraging and suggest an improvement in 
heart failure symptoms with the use of the device. In addition, published expert opinion in the cardiology literature is supportive of the clinical usefulness of CardioMEMS.  Nonetheless, there remains a dearth of 
randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be 
considered medically appropriate and necessary in this enrollees clinical management. 
 
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 CardioMEMS HF system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS HF system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
sensor (K0553). 
 
You asked the Plan to pre-approve a CGM sensor. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for coverage for CGMs and related supplies 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
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 assess 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 use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle 
Libre CGM sensor (K0553).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87364 and 87632 billed for date of service 
January 27, 2022. 
 
You asked the Plan to pay for procedure code 87634. You say that you have provided documentation to support 
payment. The Plan denied your request. The Plan says payment for code 87634 is bundled with code 87632. 
The Plan also says that code 87632 is not payable. 
 
The Plan must follow Medicare rules. In relation to code 87634, 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 87634 is a column II code to column I code 87632. 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 for code 87634.   
 
In relation to code 87632, Medicare rules state that respiratory panels with greater than five respiratory 
pathogens performed in an outpatient setting are not covered. By definition, code 87632 includes 6-11 
respiratory pathogens, so this code is not covered. Therefore, we decided that the Plan does not have to pay for 
procedure codes 87364 and 87632 billed for date of service January 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 26, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were performed at the provider's 
request and should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on January 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for spherocylinder, bifocal lenses (V2203), anti-reflective 
coating (V2750), and polycarbonate lenses (V2784) provided on June 20, 2022.  
You asked the Plan to pay for spherocylinder, bifocal lenses (V2203), anti-reflective coating (V2750), and 
polycarbonate lenses (V2784). You say that your old glasses did not work well, but your provided had retired. 
You also say that you now have a new eye doctor and received a new prescription from the new eye doctor. 
The Plan denied your request. The Plan says per the member's benefits, the plan coverage is limited to 1 pair of 
lenses and frames every 2 years. The Plan also says that they issued payment for the first eye wear purchased 
from the supplier on December 28, 2021. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one pair of standard lenses and frames every two years. 
 
We looked at the file and the Plan's rules. The Plan covers one pair of standard lenses and frames every two 
years. The record shows this benefit was exhausted on December 28, 2021. Based on this information, we 
decided that the Plan's rules for coverage of spherocylinder, bifocal lenses (V2203), anti-reflective coating 
(V2750), and polycarbonate lenses (V2784) have not been met. Therefore, we decided that the Plan does not 
have to pay for spherocylinder, bifocal lenses (V2203), anti-reflective coating (V2750), and polycarbonate 
lenses (V2784) provided on June 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95117 billed for date of service June 7, 2022. 
 
You asked the Plan to pay for procedure code 95117. You say that this patient has several allergies and requires 
injections. 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 95117 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 95117 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 95117 billed for date of service June 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need to be in rehab to get stronger or your sister 
will have to put you in a nursing home due to not being able to take care of you if you are not back to your 
normal strength and mobility. The Plan denied your request. The Plan says IRF care is not medically necessary 
as your condition can be managed at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you do not require the intensity of services provided at an IRF. Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.  Your 
care needs can be met at 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.