Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electric bone growth stimulator for the enrollee. 
 
You asked the Plan to pre-approve an electric bone growth stimulator. You say that a electric bone growth 
stimulator is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for a 
a electric bone growth stimulator are not met. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion 
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs 
have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the 
electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days.  
 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 electric bone growth stimulator. Our 
reviewer says that Medicare coverage criteria are not met. Our physician reviewer found there is no detailed 
documentation showing serial x-rays over a 3-month period demonstrative no progressive healing to support 
the diagnosis of non-union at this time. Therefore, the requested ultrasonic osteogenesis bone growth 
stimulator, is 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 an electric bone growth stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an electric bone growth stimulator for the enrollee.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for diagnostic ultrasonic guidance code for needle placement provided on 
July 12, 2021. 
 
You asked the Plan to pay for diagnostic ultrasonic guidance code for needle placement. The Plan denied your 
request. The Plan says that the diagnostic ultrasonic guidance code for needle placement is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for diagnostic ultrasonic guidance code for 
needle placement. Our reviewer says that the requested diagnostic ultrasonic guidance code for needle 
placement is considered medically reasonable and necessary in this case. Our physician reviewer found the use 
of ultrasound guidance for injection in the musculoskeletal system is very reasonable and used to ensure the 
injection of steroids into the targeted structure rather than just estimating depth etc. The procedure was 
reasonable and should be approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of diagnostic ultrasonic guidance code for needle placement have been met. 
Therefore, we decided that the Plan has to pay for diagnostic ultrasonic guidance code for needle placement 
(CPT 76942) provided on July 12, 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 laboratory services rendered by the out-of-network 
(OON) provider on November 11, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 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 laboratory services rendered by the out-of-network (OON) provider on 
November 11, 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 October 18, 
2021. 
 You asked the Plan to pay for procedure code 70450. You say that the medical records support payment for 
these services. 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 October 18, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral thermometer. 
 
You asked the Plan to pre-approve an oral thermometer. You say that an oral thermometer is medically 
necessary. The Plan denied your request. The Plan says an oral thermometer is precautionary and is not covered 
by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. This item is precautionary and is not covered. This item is available to the 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 an oral thermometer.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan. 
 
You asked the Plan to pre-approve a CT scan. The Plan denied your request. The Plan says the request cannot 
be approved because it is only supported one year after your nodule(s) was found. If the nodule is unchanged 
on the one-year study, no further imaging is supported. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan. Our reviewer says that a CT 
scan is not medically necessary. Our physician reviewer found that the enrollee is probably high risk due to 
emphysema. The nodules were stable over a 1-year period and each measure less than 4 mm in diameter. The 
radiologist was correct in citing the Fleischner Society recommendation of a 1-year follow-up in a high-risk 
patient meaning a surveillance scan in August 2022 would be reasonable. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a CT scan.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (82947) provided on March 19, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
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 82947 is a column II code to column I code 80053. 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 services (82947) 
provided on March 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections at L5-S1. 
 
You asked the Plan to pre-approve the requested injections. You say that it is felt that this should be allowed to 
diagnose facet joint pain. The Plan denied your request. The Plan says there are other likely pain generators, 
and the enrollee has radicular symptoms. This means that the criteria are not met. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are covered when there is no 
other likely cause of the enrollee's pain symptoms.  
 
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 requested injections. Our reviewer 
says that the requested treatment is not considered medically necessary based on the LCD criteria. Our physician reviewer found the enrollee is a 62 year old female with low back pain with radiculopathy both 
posterior knees (right > left), with slight weakness in the right leg. The x-rays show that there is moderate L2-3 
and L4-5 disc degeneration and grade 1 retrolisthesis of L2 on L3 and L3 on L4. 
 
The criteria require that the enrollee's pain not be associated with radiculopathy. The chart notes report that the 
pain travels to her knees and she has slight weakness in the right leg. The criteria also require that there can be 
no non-facet pathology explaining the source of the patient's pain. Since the images show a non-facet pathology 
that could explain the source of the pain, the criteria are not met. The review has determined that facet 
joint/medial branch blocks are not medically reasonable or necessary in this case. 
 
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 requested injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections at L5-S1.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary because you live 
alone, and you have two sons who also have health problems.  You said that you have no one else to help you 
at home. The Plan denied your request. The Plan says SNF care is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found from a nursing perspective, you have received 
oral medications had stable vital signs, and were treated for pain. Regarding rehabilitation services, you have 
received physical and occupational therapy.  You require contact guard assist with functional mobility 
including gait to 50 feet, and varying assistance with activities of daily living. You have no identifiable skilled 
nursing service needs. Although you have skilled therapy needs, you do not require skilled nursing or therapy 
services on a daily basis.  You do not meet severity of illness or intensity of service criteria for an inpatient 
basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the inpatient hospital care, transthoracic 
echocardiography (93306), electrocardiogram (93000), external electrocardiographic recording (93247), and 
the office visit (99203) provided from April 26, 2021, through May 28, 2021. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services provided. 
 
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 $325 copayment per admission for each medically 
necessary inpatient stay. You must pay a $10 copayment for diagnostic lab services and diagnostic procedures 
and tests (per day, per facility). You must pay a $10 copayment for each basic imaging service. Additionally, 
you must pay a $35 copayment for each in-person specialist visit.  
 
You have been asked to pay $390. This amount includes a $325 copayment for the inpatient hospital care,  
a $10 copayment x 2 for the diagnostic testing services, a $10 copayment for the basic imaging service, and a 
$35 copayment for the specialist visit provided. 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 the 
inpatient hospital care, transthoracic echocardiography (93306), electrocardiogram (93000), external 
electrocardiographic recording (93247), and the office visit (99203) provided from April 26, 2021, through 
May 28, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for occupational therapy. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is a network provider available. 
 
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 
an out-of-network referral for occupational therapy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiidra 5% drops. 
 
You asked the Plan to pre-approve Xiidra. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xiidra 5% drops.  
 Benefits for Xiidra may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a genetic panel (81220, 81225, 81226, 81227, 81230, 81238, 
81240, 81241, 81291, 81335, 81355) provided on October 20, 2021. 
 
You asked the Plan to pay for a genetic panel. You say that this is supported in the records. The Plan denied 
your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. If a laboratory assays 2 or more genes in a 
patient in parallel, then those 2 or more genes will be considered part of the same panel. A panel constitutes a 
single procedural service, so 1 code must be submitted for the panel. 
 
We find that CPT codes 81220, 81225, 81226, 81227, 81230, 81238, 81240, 81241, 81291, 81335, and 81355 
are not supported in the medical record. Specifically, these codes were used to report a panel, which should be 
billed with one code. Based on this information, we decided that Medicare rules for coverage of a genetic panel 
have not been met. Therefore, we decided that the Plan does not have to pay for a genetic panel (81220, 81225, 
81226, 81227, 81230, 81238, 81240, 81241, 81291, 81335, 81355) provided on October 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test (G0480) rendered by the out-of-network (OON) 
provider on November 23, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
 
 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the drug test (G0480) rendered by the out-of-network (OON) provider on  
November 23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy to be provided by a 
participating provider. 
 
You asked the Plan to pre-approve physical therapy. You say that the enrollee needs additional therapy. The 
Plan denied your request. The Plan says additional therapy is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the patient is near baseline in therapy and independent in a home 
exercise program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional physical therapy to be provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Medical Branch Block (MBB). 
 
You asked the Plan to pre-approve Medical Branch Block (MBB). The Plan denied your request. The Plan says 
there is no non-facet pathology per clinical assessment or radiology studies that could explain the source of the 
patient s pain, including but not limited to fracture, tumor, infection, or significant deformity. 
 
The Plan follows Medicare 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 pre-approve Medical Branch Block (MBB) to Radio 
Frequency Ablation (RFA). Our reviewer says that the MBB are not medically necessary Our physician 
reviewer found that according to the coverage criteria, facet joint injections are indicated if there is absence of 
untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst). In addition, there is no non-facet pathology per clinical assessment or radiology studies that could 
explain the source of the enrollees pain, including but not limited to fracture, tumor, infection, or significant 
deformity. The enrollees last physical therapy was over 10 years ago. In this case, the enrollee has 
radiculopathy. The review has determined that the requested medial branch blocks do not meet the Medicare 
coverage criteria. Of note, the provider's request is for 3-levels and only 2 levels can be approved as per LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Medical Branch Block (MBB) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Medical Branch Block (MBB).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a hospital outpatient clinic visit on 
December 9, 2021. 
 
You asked the Plan to waive the copayment for a hospital outpatient clinic visit. You say that the claim should 
be billed as an office visit, not outpatient surgery. The Plan denied your request. The Plan says the copayment 
you are being charged 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 a $200 
copayment for a hospital outpatient clinic visit. However, the allowed amount of the claim is $114.78 and that 
is the amount due. 
 
You have been asked to pay a $200 copayment for hospital outpatient clinic visit. A hospital outpatient clinic 
visit falls within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities 
and Ambulatory Surgical Centers benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a 
hospital outpatient clinic visit on December 9, 2021.