Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation hospital services 
you received from May 12, 2021, to May 20, 2021. 
 
You asked the Plan to waive the copayment for the inpatient rehabilitation hospital services. You say that you 
didn't know that when you were transferred to another facility from the hospital that it would mean another 
charge.  You stated that you were transferred to a facility that should have been a continuation of your stroke 
treatment. The Plan denied your request. The Plan says you were charged this copayment 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 $285 copayment per day for days 1-6, and a $0 
copayment for additional days for inpatient hospital care.  
 
Records show that you were admitted as an inpatient to an acute hospital from May 3, 2021, to May 12, 2021.  
You were then transferred to an inpatient rehabilitation hospital from May 12, 2021, to May 20, 2021. 
According to your contract, a new copayment applies each time you are admitted to the hospital.  A transfer to 
a separate facility type (such as an inpatient rehabilitation hospital) is considered a new admission. You have 
been asked to pay a $285 copayment per day for the first 6 days of your stay at the inpatient rehabilitation 
hospital, for a total of $1710. 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 inpatient rehabilitation 
hospital services you received from May 12, 2021, to May 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy 
assistant on October 15, 2020. 
 
  You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-
contracted providers at the preferred provider rate if services are not available from preferred providers. You 
say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your 
request. The Plan says the code is not appropriate for the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) 
shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they 
do not meet the qualifications of a therapist.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services 
provided by a physical therapy assistant on October 15, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound rendered on June 25, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
 
 
  
 
The provider submitted a claim for procedure codes 76700 (abdominal ultrasound) and 93976 (duplex scan of 
arterial inflow and venous outflow). Code 76700 is a column II code with a modifier indicator of 1 when billed 
with column I code 93976. Code 76700 was not billed with an appropriate modifier to allow for separate 
payment. Therefore, we decided that the Plan does not have to pay for the abdominal ultrasound rendered on 
June 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rental of a face-down recovery system provided on May 14 
to June 11, 2021. 
 
You asked the Plan to pay for a face-down recovery system. You say that the item at issue was a medical 
necessity for you. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is a 
comfort or convenience item. Therefore, we decided that the Plan does not have to pay for rental of a face-
down recovery system provided on May 14 to June 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the two x-rays and the lab services you 
received on July 8, 2021. 
 
You asked the Plan to waive the deductible for the two x-rays and lab services. You say that your insurance 
always pays for these services. The Plan denied your request. The Plan says you had not met your deductible at 
the time of these services. 
 
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 $300 deductible which applies to x-rays and lab services.  
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible which 
applies to x-rays and lab services. This cost sharing is a contractual obligation that had not been met at the time 
the two x-rays and lab services was received on July 8, 2021. Therefore, we decided that the Plan does not have 
to waive the deductible for the two x-rays and the lab services you received on July 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies, materials, and clinical staff time 
provided on June 11, 2021. 
 
You asked the Plan to pay for the additional supplies, materials, and clinical staff time. You say that the 
medical records fully support and justify the code billed. You say that the notes clearly show what kind of 
precautions were taken prior to treating the patient and the claims should be reprocessed for prompt payment. 
The Plan denied your request. The Plan says bundled services are not eligible for separate reimbursement. 
 
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 99072 is additional supplies, materials, and clinical staff 
time over and above those usually included in an office visit or other non-facility service(s), when performed 
during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease. 
 
We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status 
indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the additional supplies, materials, and clinical 
staff time have not been met. Therefore, we decided that the Plan does not have to pay for the additional 
supplies, materials, and clinical staff time provided on June 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for phototherapy services you received in a 
dermatologist's office on June 30, 2021. 
 
You asked the Plan to waive the copayment for the dermatology services. You say that you do not think it is 
fair that you have to pay a copayment when this service is completed without any contact with the doctor. The 
Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan says that 
because the allowed amount for this service ($20.84) is less than your copayment obligation, you are 
responsible for the full allowed 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 $40 
copayment for physician and professional services in a specialist's office.  
 You have been asked to pay a $40 copayment for the dermatology services. According to your contract, this 
copayment applies for any services you receive in a specialist's office, regardless of whether you see the doctor 
or not. 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 phototherapy services you received in a 
dermatologist's office on June 30, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for community psychiatric supportive treatment (H0036) 
provided on October 26, 2020. 
 
You asked the Plan to pay for community psychiatric supportive treatment. You say that the services at issue 
were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Code H0036 has a status indicator of "I" on the Physician Fee Schedule. This means that it is invalid for 
Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of 
community psychiatric supportive treatment have not been met. Therefore, we decided that the Plan does not 
have to pay for community psychiatric supportive treatment (H0036) provided on October 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that you feel that this scan is medically 
necessary as the enrollee has smoked 1 pack daily for over 39 years and has a family history of lung cancer. 
The Plan denied your request. The Plan says the records do not support that the enrollee meets the criteria for 
the LDCT. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  

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 requested LDCT scan. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the enrollee having a long tobacco use history, prior history of lung nodule 
and dyspnea, a CT is reasonable but was already requested. This request for LDCT would not provide any 
significant additional information beyond the first requested CT and is redundant. Therefore, the LDCT will be 
considered not medically necessary at this time. 
 
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 requested LDCT scan have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. 
The Plan says rules for SNF care have not been met. 
 
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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the documentation provided, you do 
not have documented skilled nursing needs. You also do not have documented skilled therapy needs. You are 
ambulating more than 100 feet and tending to activities of daily living with minimal supervision. Daily skilled 
services are not required to establish a maintenance program or to prevent deterioration of your condition. Your 
care needs, as a practical matter, can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a lumbar sympathetic nerve block. 
 
You asked the Plan to pre-approve a lumbar sympathetic nerve block. You say that the requested procedure is 
medically reasonable and necessary. The Plan denied your request. The Plan says the clinical value and 
effectiveness of a lumbar sympathetic block in the setting of intractable neuropathic pain of the knee have not 
been demonstrated in the peer-reviewed literature. 
 
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 lumbar sympathetic nerve block. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that this 70-year-old morbidly obese woman has described "neuropathic 
pain" in her right knee. She has had a right total knee arthroscopy and has had physical therapy, icing, elevation 
and medication trials with opiates and non-steroidal anti-inflammatory drugs. She had genicular nerve blocks 
but had no pain relief. The patient does not complain of burning pain, allodynia, of dysthesia. She does not 
have any of the Budapest criteria for complex regional pain syndrome. She also does not have sympathetic 
nerve dysfunction documented in the physical exam.  The physical exam and symptoms do not describe sympathetic mediated pain. The request is not medically 
reasonable or 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 a lumbar sympathetic nerve block have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a lumbar sympathetic nerve block.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy 
assistant on March 15, 2021. 
 
  You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-
contracted providers at the preferred provider rate if services are not available from preferred providers. You 
say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your 
request. The Plan says the records do not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) 
shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they 
do not meet the qualifications of a therapist.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services 
provided by a physical therapy assistant on March 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided June 25, 2021. 
 
You asked the Plan to pay for the limited oral exam. You say that you were unaware that the services would 
not be covered. The Plan denied your request. The Plan says a one-time exception has been made to process the 
claims from this date of service as in-network, however the limited oral exam is not covered under your 
benefits. 

 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation - problem focused (D0140) provided June 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo (J9299). 
 
You asked the Plan to pre-approve Opdivo. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says Opdivo to be added to the ongoing folinic acid, fluorouracil, and oxaliplatin 
(FOLFOX) chemotherapy is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Opdivo. Our reviewer says that Opdivo 
is not medically necessary.  

 Our physician reviewer found the requested use of Opdivo is not approved by the Food and Drug 
Administration (FDA) for the enrollee's diagnosis. The documentation does not support that the enrollee has a 
diagnosis of esophageal adenocarcinoma. The reviewer found that Opdivo is not supported for the requested 
use by one of the major drug compendia or by clinical research that appears in a CMS-approved medical 
journal (see appendix for list of CMS-approved journals. Therefore, the reviewer found that Opdivo is not 
medically reasonable or 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 Opdivo have not been met. Specifically, the file shows that Opdivo is not FDA-
approved for the enrollee's diagnosis. Therefore, we decided that the Plan does not have to pre-approve Opdivo 
(J9299).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan (70544) provided on July 
3, 2021. 
 
You asked the Plan to pay for a CT scan. You say that the enrollee had multiple exams. The Plan denied your 
request. The Plan says this is not separately payable without a modifier. 
 
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 a computed tomography (CT) scan (70544) provided on July 3, 
2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) cervical spine without 
contrast (72125). 
 
You asked the Plan to pre-approve the CT scan. You say that please approve the cervical CT so you can 
evaluate the cervical spine better and see if you can find a reason for her hand weakness. The Plan denied your 
request. The Plan says the records do not support that the requested CT scan is medically necessary. 
 
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 CT scan. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found an MRI cervical spine was performed on 8/18/2021 showing minimal circumferential stenosis 
at C5-6 and C6-7. Recent PET scan showed widely metastatic skeletal disease. Based on the MRI and PET 
scans sufficiently revealed the cause of her symptoms and CT would not provide any significant additional 
information to the clinical picture at this time. Therefore, the requested cervical CT will be considered not 
medically necessary at this time. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computed tomography (CT) cervical spine without contrast (72125).