Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical vision services (99214, 92250, 92285) provided 
on August 2, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for OON vision care. You say that these services were necessary and were provided 
in good faith. The Plan denied your request. The Plan says out-of-network care is covered only in certain 
limited circumstances. The provided care was not urgent or emergent and could have been performed by an in-
network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical vision services (99214, 92250, 92285) 
provided on August 2, 2021, by an out-of-network (OON) provider.
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 are not receiving the help you need at the facility 
you are at. The Plan denied your request. The Plan says the member does not meet the Medicare criteria for 
admission to an IRF. 
 
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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 epidural steroid injection provided on 
January 21, 2022. 
 
You asked the Plan to waive the copayment for epidural steroid injection. You say that you paid $195 at the 
time of service. You are not clear why you received a bill for an additional $100. The Plan denied your request. 
The Plan says coinsurance is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $295 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges.  
 
  You have been asked to pay $100 for epidural steroid injection ($295/standard copayment - $195/payment = 
$100 balance due). The epidural steroid injection falls within the Outpatient Surgery and Other Medical 
Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 epidural steroid injection provided on January 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglass frames provided on February 10, 2022. 
 
You asked the Plan to pay for eyeglass frames. You say that your frugality is being penalized since the same 
pair of glasses would cost over $700 from an in-network provider. The Plan denied your request. The Plan says 
your mandatory supplemental vision benefit exclusions include any benefits received at a non-network 
optical provider. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
 We looked at the file and the Plan's rules. The file shows that the eyeglass frames were received from a non-
network optical provider. Therefore, we decided that the Plan does not have to pay for eyeglass frames 
provided on February 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing services provided to the enrollee on January 
25, 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 this testing was not ordered or approved by the ordering provider. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be 
covered. 
 
The documentation submitted did not include a physician order/lab requisition or medical records stating 
exactly tests were to be performed. 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 pay for genetic testing 
services provided to the enrollee on January 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on October 26, 
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 the submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 
81, however, the submitted medical documentation and/or claim history indicates that the specimen was 
obtained in an office setting POS 11. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 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 laboratory services provided to the enrollee on October 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has knee osteoarthritis. She 
has not tried and failed the Plan's required drugs, Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-One. 
The records do not show that the required drugs would be contraindicated or less effective; therefore, Euflexxa 
is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Euflexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive your $50 copayment for the office visit on April 6, 2021, and 
the office visit on October 11, 2021. 
 
You asked the Plan to waive your $50 copayment for these office visits. You say that you should not have to 
pay a $50 copayment because these office visits should have been billed as routine checkups. The Plan denied 
your request. The Plan says you are responsible for a $50 copayment for each Medicare-covered office visit. 
 
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 $50 
copayment for Physician/Practitioner Services, Including Doctor's Office Visits.  
 
 You have been asked to pay a $50 copayment for office visits on April 6, 2021 and October 11, 2021. Office 
visits fall within the Physician/Practitioner Services, Including Doctor's Office Visits. 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 your $50 copayment for the office visit on April 6, 2021, and the office visit on 
October 11, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc One. 
 
You asked the Plan to pre-approve Synvisc One. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Synvisc One. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, you have not tried and failed 
the required drug(s). There is no documentation provided indicating that the plans required drug(s) would 
likely be less effective and/or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc One.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) (64635, 64636) for the 
enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that records show the enrollee did not have at least 80% reduction in pain from the 
diagnostic medial branch blocks. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The request does not 
meet the 80% pain relief criteria on both diagnostic sets. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of RFA. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation (RFA) (64635, 64636) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (70450) provided February 11, 2022. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the code billed has a bundled relationship with another code billed and 
is not separately payable.  
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 radiology services (70450) provided February 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve insertion of an ILR. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that electrocardiographic Services are covered when 
specific criteria are met. 
 
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 insertion of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a recent randomized clinical trial 
found that continuous monitoring for atrial fibrillation with an ILR (followed by treatment with oral 
anticoagulation if atrial fibrillation was detected) was not superior to usual care in reducing stroke or systemic 
embolism among patients at high risk of stroke but without a known prior history of atrial fibrillation (1). At 
this time, insertion of an ILR 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 insertion of an ILR have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of an implantable loop recorder (ILR).
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary and your needs can be provided in an alternate 
setting such as in a skilled nursing facility. 
 
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 while you have a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program such as an IRF. 
 
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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on November 11, 
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 Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. 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 pay 
for laboratory services provided to the enrollee on November 11, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for a needle electromyography (95870). We decided that the Plan does not 
have to pay for an unlisted neurological or neuromuscular diagnostic procedure (95999).  
 You asked the Plan to pay for a needle electromyography and an unlisted neurological or neuromuscular 
diagnostic procedure. You say that you have provided records to support the services billed. The Plan says that 
rules for payment have not been met because the available records do not support the codes billed. 
 
We decided that the Plan has to pay for a needle electromyography but that the Plan does not have to 
pay for an unlisted neurological or neuromuscular diagnostic procedure.  
 
The Plan follows 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 95870 is "Needle electromyography; limited study of 
muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, 
cranial nerve supplied muscles, or sphincters"; and of code 95999 is "Unlisted neurological or neuromuscular 
diagnostic procedure." 
 
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 pay for a needle electromyography. Our reviewer 
says that CPT code 95870 does meet criteria for payment in this case. However, CPT code 95999 does not 
meet criteria for payment. Our physician reviewer found that the technical report describes an 
electromyography on 4 extremities. The procedure is reported 1 unit per extremity tested. Therefore, CPT code 
95870 should be covered. However, the procedure report does not specify what procedure is being reported 
with an unlisted procedure code; therefore, CPT code 95999 cannot be verified.  
 
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 needle electromyography have been met. However, Medicare rules for 
coverage of an unlisted neurological or neuromuscular diagnostic procedure have not been met. Therefore, we 
decided that the Plan has to pay for a needle electromyography. The Plan does not have to pay for an unlisted 
neurological or neuromuscular diagnostic procedure. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical arthroscopy of the shoulder, debridement (29822-
AS-59-RT) provided on February 17, 2021. 
 
You asked the Plan to pay for arthroscopy debridement. You say that this service was billed correctly and is 
supported in the record. The Plan denied your request. The Plan says there are NCCI PTP edits between code 
29822 and codes 29824, 29827 and 29828. Although code 29822 was billed with modifier 59 to bypass these edits, the use of this modifier is not supported as the documentation does not show that this procedure is 
separate and distinct from the other procedures 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, we have confirmed that code 29822 is a column II code to column I codes 29824, 29827 and 
29828; however, 29822 was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for arthroscopy debridement. Our reviewer says that the use of 
the 59 modifier is not supported in this case. Our reviewer found per the Centers for Medicare and Medicaid 
Services, limited debridement is included in the shoulder arthroscopy procedure and would not be separately 
reported. Shoulder arthroscopy procedures include a limited debridement (CPT code 29822). Code 29822 is not 
separately payable when another shoulder arthroscopy procedure is billed and paid on the same shoulder for the 
same day for the same beneficiary at the same encounter. The documentation does not support the modifier 
reported for this service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of arthroscopy debridement have not been met. Therefore, we decided that the 
Plan does not have to pay for surgical arthroscopy of the shoulder, debridement (29822-AS-59-RT) provided 
on February 17, 2021.