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

 
We decided that the Plan does not have to pre-approve radiation therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve radiation therapy. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and it was determined 
these services can be received in-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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
radiation therapy to be provided 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 Barostim Neo system (0266T, C1825). 
 
You asked the Plan to pre-approve a Barostim Neo system. You say that the requested procedure is medically 
necessary The Plan denied your request. The Plan says medical studies have not proven that the service(s) or 
procedure(s) is helpful for treatment of the enrollee's health problem. 
 
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 Barostim Neo system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Baroreflex stimulation devices have been considered potential alternative treatments 
for resistant hypertension and heart failure. There remains an absence of randomized, blinded clinical studies 
examining long-term clinical outcomes establishing the value of Barostim Neo in patient 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 Barostim Neo system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Barostim Neo system (0266T, C1825).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. 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 the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM) and supplies.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on September 2, 2021, and October 
14, 2021. 
 
You asked the Plan to pay for the office visits. You say that you were told to see this provider if it was 
necessary even if they were out-of-network. The Plan denied your request. The Plan says if you go to a 
provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services 
you receive. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
 
  The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office 
visit provided on September 2, 2021, and October 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor supplies billed for services 
provided on January 31, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the claim 
does not match the shipping information. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery or relevant medical records which support medical 
necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain 
the necessary documentation without success.  Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the continuous glucose monitor supplies billed for services 
provided on January 31, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
to your appointments. The Plan denied your request. The Plan says you have utilized the maximum number of 
transportation trips allowed per year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee cannot lay flat. The Plan 
denied your request. The Plan says the bed is not a Medicare benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for wound care provided from August 24, 
2021, to November 9, 2021. 
 
You asked the Plan to waive the copayments for wound care. You say that paying this much for each visit is 
too much and if you would have known you wouldn't have gone to an outpatient facility. The Plan denied your 
request. The Plan says the copayments applied are 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 ambulatory surgical center, 
including but not limited to hospital or other facility charges and physician or surgical charges. 
 
 
 
 You have been asked to pay a total of $1,790.50 for the wound care. 
 
 
Date of Service Service Allowed 
Amount 
Copayment Member 
Liability 
August 24, 2021 Wound care $391.97 $295 $295 
August 31, 2021 Wound Care $203.50 $295 $203.50 
September 7, 
2021 
Wound Care $203.50 $295 $203.50 
September 14, 
2021 
Wound Care $391.97 $295 $295 
September 20, 
2021 
Wound Care $391.97 $295 $295 
September 28, 
2021 
Wound Care $203.50 $295 $203.50 
November 9, 
2021 
Wound Care $391.97 $295 $295 
Total:    $1,790.50 
 
Wound care 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 copayments 
for wound care provided from August 24, 2021, to November 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel provided on November 1, 2021. 
 
You asked the Plan to pay for the services provided. You say that you enable physicians to deliver personalized 
cancer care. The Plan denied your request. The Plan says the testing was not FDA approved. 
 
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 gene panel at issue was billed using multiple codes. If a single procedure is performed, only 
one code with one unit of service may be reported for the procedure. The file also indicates a denial for services 
was given prior to the services being rendered. 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 the 
gene panel provided on November 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on September 26, 2021. 
 
You asked the Plan to pay for the testing services. You say that you enable physicians to deliver personalized 
cancer care. The Plan denied your request. The Plan says one code must be submitted for the panel. 
 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 looked at the file and the rules. We find that the gene panel was billed with multiple codes. If a single 
procedure is performed, only one code with one unit of service may be reported for the procedure. Based on 
this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the gene panel testing provided on September 26, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a colonoscopy. 
 You asked the Plan to pre-approve a colonoscopy. The Plan denied your request. The Plan says the records do 
not show results of a colonoscopy that show a reason this test is needed. 
 
The Plan follows Medicare rules. Medicare rules say that screening colonoscopies (HCPCS G0105) may be 
paid when performed by a doctor of medicine or osteopathy at a frequency of once every 24 months for 
beneficiaries at high risk for developing colorectal cancer. 
 
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 colonoscopy. Our reviewer says that a 
colonoscopy is not reasonable and necessary Our physician reviewer found the Local Coverage Article (LCA) 
53278 allows for a colonoscopy every 2 years for high risk individuals. The provided record neither supports 
that the enrollee has a personal history of adenomas or inflammatory bowel disease nor a family history of 
colon cancer in a close relative. Our reviewer also found that the requested 5-year time frame is unsupported 
for repeat colonoscopy in a member who's last two colonoscopies were unproductive of polyps. 
 
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 colonoscopy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a colonoscopy.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on October 20, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the enrollee 
was active with hospice on the date of service. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the emergency room services provided on October 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient procedure provided on January 
17, 2022. 
 
You asked the Plan to waive the copayment for outpatient procedure. You say that you had a procedure earlier 
in the year and only had to pay $25 copayment and that's all you should have to pay now. The Plan denied your 
request. The Plan says the copayment applied 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 $150 
copayment per day for other outpatient procedures and services, including, but not limited to, diagnostic and 
therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical 
center. 
 
 You have been asked to pay $150 copayment for outpatient procedure. The outpatient procedure falls within 
the Outpatient surgery, including 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 outpatient procedure provided on 
January 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 11, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the codes remain 
not supported. 
 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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for lab services provided on December 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neurophysiology services provided to the enrollee on 
November 3, 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 records do not support the services 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, the CPT Code Manual definition of the denied codes is: 
 
CPT 95911: 
 
Nerve conduction studies; 9-10 studies 
 
 
 
 CPT 95886: 
 
Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve 
conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three 
or more nerves or four or more spinal levels (List separately in addition to code for primary procedure) 
 
CPT 95937: 
 
Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, there is no evidence 
that a nerve conduction study (NCS) was performed. Rather, pedicle screw testing was performed. This is 
considered part of the electromyography (EMG) service and code. As there was no evidence of a formal NCS 
having been performed, CPT 95911 cannot be supported. Likewise, as there was no NCS, CPT 95886 would 
not have been the correct to reference for those services provided. CPT 95937 is not otherwise eligible for 
separate billing. Train-of-four monitoring is bundled with the intraoperative neuromonitoring of 
electromyography (EMG) or motor evoked potentials (MEP) and, therefore, is not separately reportable. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for neurophysiology services provided to the enrollee on November 3, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services provided from January 
26, 2022, to March 30, 2022. 
 
You asked the Plan to pay for the services provided. You say that the provider has not been getting paid. The 
Plan denied your request. The Plan says the claim should be corrected using the correct place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The case file shows that the services at issue were billed with an incorrect 
place of service. Based on this information, we decided that Medicare rules for coverage of the services 
provided have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient mental 
health services provided from January 26, 2022, to March 30, 2022.  
 
If the provider is billing you for charges beyond any applicable cost-sharing amounts, please contact the Plan 
directly.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on July 28, 2021. 
 
You asked the Plan to pay for the services provided. You say that the independent laboratory conducted the 
tests. The Plan denied your request. The Plan says the services were not billed with an appropriate modifier. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The place of service billed on the claim indicates the enrollee was a hospital 
outpatient at the time the specimen was obtained. An independent laboratory may not bill for the technical 
component of a physician pathology service furnished to a hospital inpatient or outpatient. Based on this 
information, we decided that Medicare rules for coverage of the services provided have not been met. 
Therefore, we decided that the Plan does not have to pay for the lab testing services provided on July 28, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $107.64 copayment for an ultrasound performed on 
February 22, 2022.       
 
You asked the Plan to waive the $107.64 copayment for an ultrasound performed on February 22, 2022. You 
say that your benefits cover this procedure, and you would like this reconsidered and paid accordingly. The 
Plan denied your request. The Plan says you are responsible to pay a $107.64 copayment for an ultrasound. 
 
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 $115 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
You have been asked to pay a $107.64 copayment for an ultrasound performed on February 22, 2022. An 
ultrasound falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. 
Please note: the provider billed $964 for this service; the allowed amount was $107.64. This means that you 
have been asked to pay less than your contracted amount 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 $107.64 copayment for an ultrasound performed on February 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance angiography (MRA) of the head 
without contrast (70544). 
 
You asked the Plan to pre-approve an MRA. You say that you have a balance disorder with abnormal memory, 
and this imaging is medically necessary. The Plan denied your request. The Plan says the criteria for coverage 
of this MRA are not met. Your records do not show that you had prior scans that were unstable. The prior scans 
do not show a tumor. A previous scan does show a bulge in the wall of an artery in the head or neck, but 
records do not show that you have an upcoming surgery. 
 
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 MRA. Our reviewer says that 
Medicare criteria for coverage of an MRA are not met in this case. Our physician reviewer found that you have 
a history of a balance problem/disorder. You have had two prior MRAs in 2019 and 2021 that both returned 
normal. There was no evidence in the records provided for review that you have a condition for which surgical 
intervention would otherwise be indicated. In as much the provision of/performance of MRA would not meet 
the requirements for coverage 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 an MRA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance angiography (MRA) of the head without contrast (70544).