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

 
We decided that the Plan does not have to pay for a self-administered drug provided on March 14, 2022, and 
March 15, 2022. 
 
You asked the Plan to pay for a self-administered drug. The Plan denied your request. The Plan says self-
administered drugs are covered/reimbursable under the members medical part D coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for a self-administered drug 
provided on March 14, 2022, and March 15, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT) scan of the cervical spine for the 
enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there was no mention of neurological deficits on exam. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 scan. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found that in this patient with 
prior thoraco-lumbar fusion, since a CT myelogram has been ordered, it is reasonable to evaluate the entire 
spine with one intrathecal injection. Thus, the CT of the cervical spine is indicated in a patient with scoliosis, 
prior surgery, and upper back pain. 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
computed tomography (CT) scan of the cervical spine 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital facility services 
provided on February 18, 2022. 
 
You asked the Plan to waive the copayment for the outpatient surgery. You say that if you were aware of the 
copay, you would have rescheduled the surgery to have it done at an ambulatory surgery center. 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 $150 
copayment for an outpatient hospital facility visit.  
 
You have been asked to pay a $150 copayment for an outpatient hospital facility visit. The outpatient surgery 
falls within the Outpatient Hospital 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 outpatient hospital facility services provided on February 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nuedexta. 
 
You asked the Plan to pre-approve Nuedexta. You say that you would like the Plan to reconsider their denial. 
The Plan denied your request. The Plan says Nuedexta is not covered under the enrollee's Medicare Part B 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nuedexta.  
 
Benefits for Nuedexta may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74176-26 billed for date of service March 14, 
2022. 
 
You asked the Plan to pay for procedure code 74176-26. You say that this was denied incorrectly as a 
duplicate. 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 March 25, 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 procedure code 74176-26 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 74176-26 billed for date of service 
March 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service January 25, 
2022. 
 You asked the Plan to pay for procedure code 70544. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70544 is bundled into payment for 
code 70551. 
 
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 70544 
is a column II code to column I code 70551. 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 70544 billed for date of service January 25, 
2022.
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 3, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. 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 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro powered extremity range of motion device 
for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the studies on the MyoPro have not yet shown that outcomes for stroke rehabilitation are 
significantly improved compared with supervised therapy alone. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that based on the medical records provided and current clinical guidelines, there is no documentation that 
the MyoPro powered extremity range of motion device at issue in this case meets Medicare criteria for being 
medically reasonable and necessary. Current clinical guidelines designate robotic therapy to be of "uncertain 
utility compared with dose-matched conventional upper limb exercise therapies" with unproven benefit in the 
home environment. Although records from the device manufacturer/vendor argue medical necessity of the 
requested device, no records from the enrollee's actual treating provider clarify why the requested device is the most appropriate treatment for the enrollee's condition. The records from the enrollee's provider only state that 
he "may benefit" from the requested device with no further details provided. This is inadequate to meet 
Medicare criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a MyoPro powered extremity range of motion device for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 4, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. 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 April 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 77067 and 77063 billed for date of service 
March 9, 2022. 
 You asked the Plan to pay for procedure codes 77067 and 77063. You say that the patient had multiple exams 
on this date of service. The Plan denied your request. The Plan says payment for codes 77067 and 77063 is 
bundled into payment for code 77066. 
 
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 
77067 and 77063 are column II codes to column I code 77066. 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 codes 77067 and 77063 billed for 
date of service March 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits (code 99213) and the therapeutic procedures 
(code 97112) provided by a chiropractor from April 6, 2022, to April 13, 2022. 
 
You asked the Plan to pay for procedure codes 99213 and 97112. You say that you believe the provider billed 
incorrect procedures. The Plan denied your request. The Plan says thee two codes are not manual manipulation 
of the spine.  Manual manipulation of the spine is the only service covered by a chiropractor. 
 
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.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visits (code 99213) and the therapeutic procedures (code 97112) 
provided by a chiropractor from April 6, 2022, to April 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70480 billed for date of service March 18, 
2022. 
 
You asked the Plan to pay for procedure code 70480. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70480 is bundled into payment for 
code 70450. 
 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 70480 
is a column II code to column I code 70450. 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 70480 billed for date of service March 18, 2022.
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 11, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. 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 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tadalafil. 
 
You asked the Plan to pre-approve Tadalafil. The Plan denied your request. The Plan says this drug is not 
eligible for coverage under the Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tadalafil.  
 
 
 Benefits for Tadalafil may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an out-of-network chiropractic visit 
provided on June 25, 2021. 
 
You asked the Plan to waive the copayment for an out-of-network chiropractic visit. You say that if you had 
known that the provider was out-of-network, you would not have started treatment. The Plan denied your 
request. The Plan says the copayment applied was 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 $55 
copayment for chiropractic services.  
 
You have been asked to pay the allowed amount of $40 which is less than the $55 copayment for an out-of-
network chiropractic visit. An out-of-network chiropractic visit 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. Therefore, we decided that the Plan does not have to waive the copayment for an out-of-network chiropractic 
visit provided on June 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 7, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. 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 April 7, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service April 4, 
2022. 
 
You asked the Plan to pay for procedure code 76700. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for 
code 93976. 
 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 76700 
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 the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76700 billed for date of service April 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 2, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. 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 April 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided on December 17, 2021. 
 
You asked the Plan to pay for the acupuncture services. You say that acupuncture is covered for the patient's 
diagnosis. The Plan denied your request. The Plan says the provider of these acupuncture service is not eligible 
for Medicare payment. 
 
The Plan must follow Medicare rules. Medicare rules say that acupuncture services are only covered when 
provided by physicians or physician assistants (PA), nurse practitioners (NP), clinical nurse specialists (CNS), 
or auxiliary personnel.  If provided by auxiliary personnel, the provider must be under the appropriate level of 
supervision of a physician, PA, or NP/CNS.  In this case, the acupuncture services were provided by a licensed 
acupuncturist, meaning that they were provided by auxiliary personnel.  You have not provided any evidence 
that this provider was under the appropriate supervision of one of the provider types listed above. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the acupuncture services have not been met. Therefore, we decided that the Plan does not have to 
pay for acupuncture services provided on December 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methotrexate tablets. 
 
You asked the Plan to pre-approve Methotrexate tablets. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says Methotrexate tablets are not covered under the 
enrollee's Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Methotrexate tablets.  
 
Benefits for Methotrexate tablets may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six additional physical therapy visits for the enrollee. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says to continue to meet medical necessity criteria for additional physical 
therapy (PT), a progress report is required and will provide meaningful information regarding the enrollee's 
response to the initial approved visits. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 additional visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. The requested additional visits are not medically reasonable or necessary. Our physician reviewer 
found that in this case, the enrollee has previously been treated with outpatient therapies and should be 
independent with a home exercise program. There is no documentation of continued progress with therapy to 
support additional therapy. The additional therapy services are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve six additional physical therapy visits for the enrollee.