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

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablations.
You asked the Plan to pre-approve genicular nerve radiofrequency ablations. You say that the services are
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore,
coverage criteria 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 genicular nerve radiofrequency
ablations. Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found genicular nerve blocks and genicular nerve
radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic
knee pain, including, but not limited to any of the following: degenerative joint disease; osteoarthritis of the
knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for
individuals who are not candidates for knee replacement surgery. The review has determined that the requested
genicular nerve radiofrequency ablations are 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 genicular nerve radiofrequency ablations have not been met. Therefore, we
decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablations.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded 99100 provided on January 29, 2021.
You asked the Plan to pay for the anesthesia 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 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 99100 is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 99100 provided on January 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for an electrocardiogram provided to the enrollee on October 25, 2020.
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 an appropriate modifier was not 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 93010 is a column II code to column I code 62270. 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 an electrocardiogram provided to the enrollee on October 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan of the chest (71250) provided on
June 3, 2021.
You asked the Plan to waive the copayment for a CT scan of the chest. You say that you should be reimbursed
the full amount you paid because you had to go through needless loss of time and worry. The Plan denied your
request. The Plan says the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250
copayment for advanced imaging services.
You have been asked to pay the Medicare-allowed charge of $157.75 for a CT scan of the chest. A CT scan of
the chest falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category.
This means that you have been asked to pay less than or equal to the correct amount based on your contract
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the copayment for a CT scan of the chest (71250)
provided on June 3, 2021.
If the provider is billing or has billed you for charges beyond any applicable cost-sharing amounts, please
contact the Plan directly.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day sensor.
You asked the Plan to pre-approve a Freestyle Libre 14-day sensor. 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 must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle
Libre 14-day sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14-day sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) provided on May
27, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that the assisted living facility is
responsible to obtain prior authorization for all of their patients, which should also cover for the medical
treatments provided by the doctor. The Plan denied your request. The Plan says enrollee's must receive their
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered.
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 domiciliary or rest home visit (99336)
provided on May 27, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the angiography rendered on March 16, 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 procedure code 75710 is not supported.
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 75710 is angiography, extremity, unilateral, radiological
supervision and interpretation.
We find that CPT code 75710 is not supported in the medical record. Specifically, there is no documentation of
a unilateral extremity angiography with radiological supervision and interpretation. 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 pay for the angiography rendered on March 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 18, 2020.
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 were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an assisted living facility setting
and should have been billed with POS code 13. Therefore, we decided that the Plan does not have to pay for the
laboratory services rendered on November 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for provider services with a specialist (78452, 93017, 93016) rendered on May 18, 2021. You also asked the Plan to waive the coinsurance for a regadenoson injection (J2785) rendered on May 18, 2021.
You asked the Plan to waive the copayment for provider services with a specialist. You say that you were late for your appointment with the specialist provider, so the office staff told you to see a different provider. You also say that no one informed you this other provider was not in network. The Plan denied your request. The Plan says you were 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 $50 copayment in a specialist's office. Your contract with the Plan also clearly says that you must pay a 20%
coinsurance for Medicare Part B covered drugs in a specialist's office. You have been asked to pay a $50 copayment for provider services with a specialist. You have also been asked to pay $48.40 in coinsurance, which is 20% of the allowed amount for a regadenoson injection ($242 allowed amount x 20% coinsurance = $48.40). Regadenoson injections fall within the Medicare Part B Prescription Drugs 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 provider services with a specialist (78452, 93017, 93016) rendered on May 18, 2021. You also asked the Plan to waive the coinsurance for a regadenoson injection (J2785) rendered on May 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) provided on May
28, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that the assisted living facility is
responsible to obtain prior authorization for all of their patients, which should also cover for the medical
treatments provided by the doctor. The Plan denied your request. The Plan says enrollee's must receive their
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered.
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 domiciliary or rest home visit (99336)
provided on May 28, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on June 22, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The 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 physician services provided to the enrollee on June 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aduhelm.
You asked the Plan to pre-approve Aduhelm. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Aduhelm. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that Aduhelm is medically reasonable and necessary for you in this case. The magnetic resonance imaging (MRI) imaging in this case suggests the presence of cerebrovascular disease, which is evidence of a mixed etiology for your symptoms. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have to pre-approve Aduhelm.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular junction testing rendered on April 8,
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 95937 (neuromuscular junction test) and 51784
(electromyography studies). Code 95937 is a column II code with a modifier indicator of 1 when billed with
column I code 51784. Code 95937 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 neuromuscular junction testing rendered on
April 8, 2021
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an electrocardiogram (93005) and a computed tomography scan (74177) provided on June 25, 2021.
You asked the Plan to pay for an electrocardiogram and a computed tomography scan. You say that these services were billed correctly. The Plan denied your request. The Plan says these codes cannot be paid.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We find that CPT codes 93005 and 74177 are not supported in the medical record. Specifically, medical records documenting these services have not been submitted. Based on this information, we decided that Medicare rules for coverage of an electrocardiogram and a computed tomography scan have not been met. Therefore, we decided that the Plan does not have to pay for an electrocardiogram (93005) and a computed tomography scan (74177) provided on June 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the sacroiliac (SI) joint injection rendered on July 13, 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 covered.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value cannot be paid when the MAI value is 2.
In this case, the MUE for CPT code 64451 is 2. The MAI value for this code is 2. You billed 3 units of this
code, exceeding the MUE. 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 pay for the sacroiliac (SI)
joint injection rendered on July 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prochlorper.
You asked the Plan to pre-approve Prochlorper. You say that the medication is necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that oral anti-emetic drugs that are used as full
replacement for intravenous dosage forms of a cancer regimen are covered under specific circumstances.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of Prochlorper have not been met. Therefore, we decided that the Plan does not have to pre-approve
Prochlorper
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 9, 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 covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal, molecular genetic screening, was requested solely for screening purposes.
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not
have to pay for the laboratory services rendered on July 9, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on June 7, 2021.
You asked the Plan to pay for psychotherapy services. You say that the medically necessary services at issue
were provided to the enrollee in good faith. 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 the clinical psychologist or clinical social worker
will attempt to consult with the enrollee's attending or primary care physician.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of psychotherapy services have not been met. Specifically, the provided records do not document an
attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we
decided that the Plan does not have to pay for psychotherapy services (90832) provided on June 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyeglasses provided on July 19, 2021.
You asked the Plan to pay an additional amount for eyeglasses. The Plan denied your request. The Plan says
you are responsible for anything over $100 for vision services provided in-network or out-of- network.
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. The Plan
covers these services with $100 (combined in and out-of-network) benefit toward the purchase and fitting of
eyeglasses and pair of lenses or contact lenses (1 per calendar year).
We looked at the file and the Plan's rules. The file shows that the Plan paid the correct vision benefit amount.
Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on
July 19, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to hold you harmless for outpatient surgery services provided on April 14, 2021.
You asked the Plan to hold you harmless for outpatient surgery services. You say that you have never had to pay extra for services until now. The Plan denied your request. The Plan says that the correct coinsurance was applied.
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 enrollees must pay a $0 copayment for outpatient surgery received in an outpatient hospital or ambulatory surgical center. The Plan says you must pay $543.90, or 20% coinsurance, for outpatient surgery services. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for outpatient surgery services. Therefore, we decided that the Plan has to hold you harmless for outpatient surgery services provided on April 14, 2021.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Corus CAD testing rendered on May 29, 2020.
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 testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal, Corus CAD cardiovascular risk assessment panel, was requested solely for
screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that
the Plan does not have to pay for the Corus CAD testing rendered on May 29, 2020.