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

 
We decided that the Plan does not have to pay for the wrist x-rays (73130) for the left and right wrists provided 
on September 28, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the x-rays. You say that the radiologist does not read the films based solely on 
the enrollee's insurance. You also say that this could jeopardize the enrollee's health. The Plan denied your 
request. The Plan says the claim processed correctly. 
 
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 wrist x-rays (73130) for the left and right 
wrists provided on September 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 the services provided by a chiropractor from January 3, 
2022, to January 17, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
covered. 
 
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 services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the services provided by a chiropractor from January 3, 2022, to January 
17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of care with an out of network (OON) 
provider. 
 You asked the Plan to pre-approve a continuation of care with an OON provider. You say that you have been 
seeing the enrollee since January of 2022. The Plan denied your request. The Plan says the enrollee must use 
network providers, and no clinical information was provided to show a necessity to continue care out of 
network. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 continuation of care with an OON 
provider. Our reviewer says that the criteria for coverage of OON care have not been met. Our physician 
reviewer found the enrollee has chronic low back pain. She takes Gabapentin and Tramadol for pain. The 
enrollee has done physical therapy and has tried over the counter NSAIDs and heat. An epidural steroid 
injection is a simple procedure that is available from network providers. There is nothing unique about the 
enrollee's condition that would make it medically necessary for the enrollee to continue care with the OON 
provider as requested. The Plan has shown that they have network specialists who have the qualifications and 
the expertise necessary to meet the current medical Standards of Care required for treatment of the enrollee's 
condition. The enrollee's medical management and follow-up care can be safely transitioned to a network 
specialist 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 a continuation of care with an OON provider have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuation of care with an out of network (OON) 
provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for special radiation treatment procedure (77470) provided on 
January 10, 2022. 
 
You asked the Plan to pay for the special treatment procedure. You say that this service was pre-approved and 
is supported in the record. The Plan denied your request. The Plan says a National Correct Coding Initiatives 
(NCCI) Procedure to Procedure (PTP) edit exists between G6015 and 77470. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was 
not billed with this PTP code edit. This service was not billed appropriately by Medicare coding regulations. 
 
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 77470 
is a column II code to column I code G6015. 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 special radiation treatment procedure (77470) provided on 
January 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing for Humira (80145) and a column 
chromatography (82542) provided on July 10, 2021. 
 
You asked the Plan to pay for drug testing for Humira and a column chromatography. You say that the services 
at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for 
payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 80145 and 82542 have a Status Indicator of X on the Physician Fee Schedule. This 
means that CPT code 80145 and 82542 are not valid for Medicare purposes. Based on this information, we 
decided that Medicare rules for coverage of drug testing for Humira and a column chromatography have not 
been met. Therefore, we decided that the Plan does not have to pay for drug testing for Humira (80145) and a 
column chromatography (82542) provided on July 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service February 
3, 2022. 
 You asked the Plan to pay for procedure code 70450-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 70450-26 is bundled into 
payment for code 70496-26. 
 
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 
70450-26 is a column II code to column I code 70496-26. 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 procedure code 70450-26 billed for date of service 
February 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the needle placement (36000) provided on December 6, 
2021. 
 
You asked the Plan to pay for the needle placement. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says CPT code 36000 has a status indicator of B. 
 
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 CPT code 36000 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 36000 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the needle placement have not been met. Therefore, we decided that the Plan does not have to pay for the 
needle placement (36000) provided on December 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 1, 2022 by an 
out-of-network (OON) provider. 
 
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. 
 
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 laboratory services provided on February 1, 
2022 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will not be able to recover without 
intense therapy and medical assistance. The Plan denied your request. The Plan says that the request does not 
meet medical necessity. 
 
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 physician reviewer found 
that the complexity of the enrollees nursing, medical and rehabilitation needs do require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. His medical status does require intensive 
physician and nursing oversight in an IRF. He is noted to have some bleeding from the penis status post stent 
removal. He has right lower quadrant abdominal pain. Although he is overall hemodynamically stable, he 
needs monitoring of these conditions, as well as monitoring of his complete blood count (CBC), magnesium 
levels, and hypocalcemia. He will benefit from medical management from his complex condition as well as 
additional multiple therapies, including physical and occupational therapy. He is motivated but deconditioned. 
Therefore, 15 hours over 7 consecutive days of therapy services will likely be most appropriate. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 7, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 procedure code 70450 billed for date of service February 7, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 2, 2022. 
 
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. The rules say that a professional component (PC)/technical component 
(TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment 
may be made only if the physician interprets an abnormal smear for hospital inpatient. 
 
We looked at the file and Medicare rules. Billed procedure code 85060 has a PC/TC indicator of 8 and the file 
shows that the services were performed in the outpatient setting. Therefore, we decided that the Plan does not 
have to pay for the laboratory services rendered on January 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite crown, anterior, (D2390) provided 
on February 15, 2022. 
 
You asked the Plan to pay for the dental service. You say that the enrollee's fillings were so big they wrapped 
around the teeth. The Plan denied your request. The Plan says the claim processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the resin-based composite crown is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-
based composite crown, anterior, (D2390) provided on February 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 26, 2022. 
 
You asked the Plan to pay for the office visit. You say that this was an initial appointment to set up as a patient 
and to help maintain a tolerable level of pain. You say that your disability income does not allow for extra bills 
and you hope the bill will be paid. The Plan denied your request. The Plan says the manual manipulation of the 
spine has been paid and the office visit remains denied. 
 
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 office visit provided on January 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myoelectric prosthetic arm with independently 
articulating digits 
 
You asked the Plan to pre-approve myoelectric prosthetic arm with hand features. You say that long delays for 
insurance authorization, and the refusal to authorize medically necessary myoelectric devices are harmful to 
patients and costly to the payer. The Plan denied your request. The Plan says the prosthetic arm with hand 
features exceeds the enrollee's needs and is not medically necessary. 
 
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 myoelectric prosthetic arm with hand 
features. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found in this case, the requested myoelectric prosthesis is used 
for the upper extremity. It is an arm prosthesis that is motorized. The requested device has not been shown to 
be superior to other standard treatments for the medical condition.  The documentation does not show that the 
enrollee has failed treatment with a body-powered upper extremity prosthesis. The requested prosthesis is not 
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 myoelectric prosthetic arm with hand features have not been met. Therefore, we 
decided that the Plan does not have to pre-approve myoelectric prosthetic arm with independently articulating 
digits
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry rendered on November 10, 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 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 83789 is a column II code to column I code G0480. 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 the mass spectrometry 
rendered on November 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided by an out-of-network provider on 
February 17, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 
17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hot or cold packs therapy rendered on January 31, 2022. 
 
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 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 CPT code 97010 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 97010 is not separately payable. 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 hot or 
cold packs therapy rendered on January 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the open treatment of femoral supracondylar or transcondylar 
fracture without intercondylar extension services coded 27511 provided on December 4, 2021. 
 You asked the Plan to pay for the open treatment of femoral supracondylar or transcondylar fracture without 
intercondylar extension 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 27511 
is a column II code to column I code 27487. 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 the open treatment of femoral supracondylar or transcondylar 
fracture without intercondylar extension services coded 27511 provided on December 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 24, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 procedure code 70450 billed for date of service January 24, 
2022.