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

 
We decided that the Plan does not have to pre-approve a duplex scan of extracranial arteries (93880) 
 
You asked the Plan to pre-approve a duplex scan of extracranial arteries. You say that you would like this 
denial to be overturned. The Plan denied your request. The Plan says this test is not reasonable or necessary at 
this time. 
 
The Plan follows Medicare rules. Medicare rules say that non-invasive vascular studies are considered 
medically necessary if the ordering physician has reasonable expectation that their outcomes will potentially 
impact the clinical management of the patient. 
 
 
  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 duplex scan of extracranial arteries. 
Our reviewer says that a duplex scan of extracranial arteries is not reasonable and necessary. Our physician 
reviewer found the physical exam reveals no carotid bruits or jugular venous distention, and carotid upstrokes 
are normal. There is a grade 1-2 systolic ejection cardiac murmur at the base. Our reviewer found that a recent 
stress test was normal, and an echocardiogram showed mild left atrial dilation, mild mitral regurgitation with 
mitral annular calcification and a mildly calcified aortic valve. The documentation does not support the 
rationale for this imaging study. Guidelines do not support a need for carotid duplex scan extracranial bilateral 
study (93880). Our physician reviewer also found that at this time cardiac doppler imaging would not be 
considered medically appropriate and necessary in this patients 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 duplex scan of extracranial arteries have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a duplex scan of extracranial arteries (93880)
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on December 7, 2021, by an out-of-
network provider. 
 
You asked the Plan to pay for the office visit. You say that you were not told the provider was out-of-network. 
The Plan denied your request. The Plan says you are covered for office visits; however, your plan requires you 
to be seen by in-network providers unless authorized to be seen out-of-network. 
 
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 office visit provided on December 7, 2021, by 
an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to lower the $60 copayment for urgent care services provided on 
February 16, 2022. 
 
You asked the Plan to lower the $60 copayment for urgent care services provided on February 16, 2022. You 
say that you should only be responsible for a $20 copayment. The Plan denied your request. The Plan says you 
are responsible for a $60 copayment per urgent care 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 $60 
copayment for Urgently Needed Services.  
 
You have been asked to pay a $60 copayment for urgent care services. Urgent care services fall within the 
Urgently Needed 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 lower the $60 copayment for urgent care services provided on February 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on December 6, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. You say that this appeal should be granted because the services 
provided were medically necessary and meet all applicable professionally recognized standards of healthcare. 
The Plan denied your request. The Plan says this provider is a non-network provider who does not work with 
the member's health plan, and the member self-directed for care. The Plan also says the member's primary care 
provider did not refer for services. 
 
 
 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 psychotherapy provided on December 6, 2021, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a below-knee prosthesis and related supplies 
 
You asked the Plan to pre-approve a below-knee prosthesis and related supplies. You say that the requested 
items are a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity 
rules for coverage of the requested items have not been met. 
 
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 below-knee prosthesis and related 
supplies. Our reviewer says that the requested items are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that only very limited records have been provided; the latest 
examination of the enrollee that has been provided is from February 2022. A prosthetist's note from March 2022 contains conflicting information as to whether the amputation is on the left or the right side. Inadequate 
consistent and up-to-date information is provided on the enrollee's condition and functional status to meet 
Medicare criteria for coverage for the requested prosthetic device and accessories. 
 
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 below-knee prosthesis and related supplies have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a below-knee prosthesis and related supplies
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted nervous system procedure (64999) provided on 
November 15, 2021. 
 
You asked the Plan to pay for the unlisted nervous system procedure (64999). You say that this is a covered 
charge and the service was medically necessary. You say that the medical records should be reviewed, and the 
claim reprocessed for payment. The Plan denied your request. The Plan says procedure code 64999 is not 
supported by the medical records submitted. 
 
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 64999 is unlisted procedure, nervous system. 
 
  We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the unlisted nervous system procedure (64999). Our reviewer 
says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer 
found that the documentation is not clear on what procedure the unlisted procedure code is being reported for. 
Therefore, this procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the unlisted nervous system procedure (64999) have not been met. Therefore, 
we decided that the Plan does not have to pay for the unlisted nervous system procedure (64999) provided on 
November 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on February 9, 2022. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
you have been having a difficult time with claims when it comes to billing, and it is not your fault as to why 
they are billed incorrectly. The Plan denied your request. The Plan says this service does not meet the criteria 
for coverage. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 the non-emergency ambulance 
transportation and ground mileage. Our reviewer says that the documentation does not support that the 
ambulance transport on February 9, 2022 was medically reasonable and necessary. Our physician reviewer 
found the documentation does not support that other means of transport (such as stretcher van, wheelchair van, 
taxi, private car, or other type of vehicle) were contraindicated for you on February 9, 2022. Our physician 
reviewer also found that the documentation does not support that you needed the expertise, services and 
lifesaving and life-sustaining equipment that only a fully-equipped ambulance could provide for safe transport 
on February 9, 2022. 
 
 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 non-emergency ambulance transportation and ground mileage have not been 
met. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transportation 
(A0428) and ground mileage (A0425) provided on February 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an Apple Watch provided on February 25, 2022. 
 You asked the Plan to pay for Apple Watch. You say that you need this and can be reimbursed up to $255 for 
it. The Plan denied your request. The Plan says the denial of additional payment is correct, because the Plan has 
paid the full $150 Wellness Bucks benefit to you. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The Plan has a Wellness Bucks supplemental benefit that goes beyond Medicares coverage. 
For that reason, the Plans rules apply to this case. The Plan covers reimbursement for activity/fitness trackers 
and other wellness expenses up to a combined $150 per year. 
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. The Plan has 
already reimbursed you the full $150 Wellness Bucks benefit for 2022; therefore, you are responsible for all 
costs above this amount. Therefore, we decided that the Plan does not have to pay for an Apple Watch provided 
on February 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of any joint (the 
right shoulder) (73221). 
 
You asked the Plan to pre-approve an MRI of the right shoulder. You say that the enrollee has provocative 
testing on physical exam suggestive of shoulder impingement. The Plan denied your request. The Plan says this 
request cannot be approved because results of an x-ray taken after the enrollee's symptoms started or changed 
that show a need for further imaging must be provided. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI of the right shoulder. Our 
reviewer says that an MRI of the right shoulder is not reasonable and necessary. Our physician reviewer found 
on a physical exam, provocative tests suggestive of right shoulder pathology. And x-ray of the cervical spine 
was provided without date of result. A five-to-six-year history of a fall on the right side of the body was 
provided. Our reviewer found that treatment with physical therapy, Gabapentin and Robaxin was provided 
without dates of treatment. There were no x-rays of the right shoulder provided for review. There is no specific 
clinical ration for the requested MRI of the right shoulder. Our physician reviewer also found that there has 
been no documented course of conservative therapy. 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the right shoulder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of any joint (the right shoulder) 
(73221).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the eye exam (92004), determination of refractive state 
(92015), and frames (V2020) provided on February 18, 2022. 
 
You asked the Plan to pay more for the eye exam, determination of refractive state, and frames. You say that 
you believe these services should be covered in full. The Plan denied your request. The Plan says your benefit 
has a dollar maximum, and you have met the limit for these services. 
 
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 up to $75 per calendar year for a routine vision exam, and also covers up to $220 per 
calendar year for routine vision hardware. 
 
We looked at the file and the Plan's rules. The record shows that the Plan paid the allowance of $75 toward the 
eye exam (92004), determination of refractive state (92015), and also paid the $220 allowance toward the 
bifocal lens (V2200) and polycarbonate or equal lens (V2784), and your routine vision exam and routine vision 
hardware allowance benefits have been exhausted. Based on this information, we decided that the Plan's rules 
for coverage of the eye exam, determination of refractive state, and frames have not been met. Therefore, we 
decided that the Plan does not have to pay more for the eye exam (92004), determination of refractive state 
(92015), and frames (V2020) provided on February 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray provided on February 4, 2022. 
 
You asked the Plan to pay for the x-ray. You say that your chiropractic treatments were denied when you 
relocated, and you ended up facing a balance due. You say that there is established proof of benefits to 
receiving chiropractic adjustments. The Plan denied your request. The Plan says Medicare does not cover x-
rays rendered 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 x-ray provided on February 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services provided on February 15, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the podiatry services. You say that you are appealing the denied service. The 
Plan denied your request. The Plan says the rendering provider is an OON provider, and they never received 
the medical records to determine if the service was urgent or emergent. 
 
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 podiatry services provided on February 15, 
2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator for the enrollee.  
You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied 
your request. The Plan says this request does not meet the criteria for recertification. 
 
The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 concentrator Our reviewer says that 
the requested concentrator is medically reasonable and necessary. Our physician reviewer found that the 
enrollee has been on oxygen during sleep. There is a documented oxygen saturation of 77% during sleep one 
year ago. A recent in-person medical visit addressed the continued need for oxygen at night. Medicare does not 
require annual re-documentation of hypoxemia off of oxygen for patients whose circumstances have not 
changed. This patient's dementia and confusion may make overnight oximetry or a sleep study difficult or 
impractical. 
 
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 concentrator have been met. Therefore, we decided that the Plan does not 
have to pre-approve an oxygen concentrator for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Spinal Simplicity interspinous-interlaminar fusion 
device (CPT code(s): 22840 and 22612). 
 
You asked the Plan to pre-approve the services. You say that this technology has been Food and Drug 
Administration (FDA) approved, it would have a significant impact on the enrollee's quality of life and not 
living in constant pain. The Plan denied your request. The Plan says the Medicare criteria for reasonable and 
necessary are not met because use of this device as a stand-alone procedure has not been shown to be safe and 
effective in long term studies. The Plan states this device is not approved for use in a stand-alone procedure as 
requested by the enrollee's pain practitioner provider. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found interlaminar devices remain experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Spinal Simplicity interspinous-interlaminar fusion device (CPT code(s): 22840 and 
22612).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 20, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not a covered benefit. 
 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on December 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two pairs of bifocal safety goggles. 
 
You asked the Plan to pre-approve the bifocal safety goggles. You say that you cannot use regular glasses and 
cannot afford these two pairs of safety goggles. The Plan denied your request. The Plan says Medicare does not 
cover bifocal safety goggles. 
 
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 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve two pairs of bifocal safety goggles.