Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH admission is medically 
necessary. The Plan denied your request. The Plan says an LTACH admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not already 
available at the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous.  
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit rendered on September 7, 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. The rules say that follow-up services are included in the global surgical 
package. 
 
We looked at the file and Medicare rules. Procedure code 99213 was related to and billed within 90 days of 
major surgical procedure 63655 billed on June 13, 2022. Payment for code 99213 is included in the global 
surgical package. Therefore, we decided that the Plan does not have to pay for the office visit rendered on 
September 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a medical alert system (E1399). 
 
You asked the Plan to pre-approve the medical alert system. You say that this item is medically necessary. The 
Plan denied your request. The Plan says this item is non-covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a medical alert system (E1399).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a positron emission tomography/computed tomography 
(PET/CT) scan provided to the enrollee on July 21, 2022. 
 
You asked the Plan to pay for the services. You say that you had surgery the day after the scan to remove a 
melanoma and two lymph nodes. The Plan denied your request. The Plan says the scan performed in this case 
added little information beyond what could be obtained with sentinel lymph node biopsy. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 pay for the services. Our reviewer says that the scan 
at issue in this case was not medically reasonable or necessary. Our physician reviewer found that your state of 
melanoma was pT2, and a sentinel node procedure had been scheduled prior to the planned excision. No report 
of the sentinel node procedure was provided in the records. Medicare may approve PET/CT for melanoma 
equal to or greater than stage III. This is not the case here. The PET/CT did not provide any more information 
than would have been available had the planned nuclear medicine sentinel node study been done. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for a positron emission tomography/computed tomography (PET/CT) scan provided to the enrollee 
on July 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 monoclonal antibody treatment received on 
November 9, 2021. 
 
You asked the Plan to pay for the treatment. You say that this should be paid for. The Plan denied your request. 
The Plan says this is paid by Original Medicare. 
 
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 COVID-
19 monoclonal antibody treatment received on November 9, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for nonsurgical wound dressing provided on 
October 09, 2022. 
 
You asked the Plan to waive the copayment for nonsurgical wound dressing. You say that you are disputing the 
share cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $90 
copayment for Emergency care. 
 
You have been asked to pay a $90 copayment for nonsurgical wound dressing. This item/service falls within 
the Emergency care 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 nonsurgical wound 
dressing provided on October 09, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone growth stimulator. 
 
You asked the Plan to pre-approve the stimulator. You say that this should be paid for. The Plan denied your 
request. The Plan says the requirements have not been 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 the stimulator. Our reviewer says that 
the requested stimulator is not medically reasonable or necessary. Our physician reviewer found that the 
provided records do not document nonunion of a long bone fracture (where the fracture healing has ceased in 2 
sets of radiographs, each including multiple views of the fracture site, separated by a minimum of 90 days prior 
to starting treatment with the electrical osteogenic stimulator) or failed fusion, where a minimum of 9 months 
has elapsed since the last surgery or a congenital pseudarthroses as required. 
 
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 stimulator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a bone growth stimulator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that your current custom orthotics are worn down. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for CT Scan provided on September 02, 2022. 
 
You asked the Plan to waive the copayment for CT Scan. You say that you never had to pay a copayment 
before. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $250 copayment for CT Scan. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies 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 CT Scan provided on September 02, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac monitoring services provided on July 06, 2022. 
 
You asked the Plan to pay for cardiac monitoring services. You say that you were not aware that authorization 
was required. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for cardiac monitoring 
services provided on July 06, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care to be provided after a left 
reverse total shoulder arthroplasty. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that acute inpatient hospital care is 
medically necessary. The Plan denied your request. The Plan says acute inpatient hospital care is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found that the provided documentation did not clearly reveal any unstable 
condition or indication for needing acute care services that would likely cross two midnights for this typically 
low risk ambulatory procedure.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care to be provided after a left reverse total shoulder 
arthroplasty.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on September 
07, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that this should be covered. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $350 
copayment for Outpatient surgery. 
 
You have been asked to pay a $350 copayment for outpatient surgery. This item/service falls within the 
Outpatient surgery 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 surgery 
provided on September 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Injection single tendon sheath provided on 
June 06, 2022. 
 
You asked the Plan to waive the coinsurance for Injection single tendon sheath. You say that you should not 
have to pay this, you did not see it in the evidence of coverage. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 
 
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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for Injection single tendon sheath. This item/service falls 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 coinsurance 
for Injection single tendon sheath provided on June 06, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPAP provided on May 28, 2022. 
 
You asked the Plan to pay for CPAP. You say that you called the Plan and were told if you purchase a CPAP 
out-of-pocket it would be reimbursed. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for CPAP provided on May 
28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95822, 95909, 95886, and 95999 provided 
on February 14, 2022. 
 
You asked the Plan to pay for procedure codes 95822, 95909, 95886, and 95999. You say that the medical 
records support the billing of codes 95822, 95909, 95886, and 95999. The Plan denied your request. The Plan 
says the medical records do not support the billing of codes 95822, 95909, 95886, and 95999. 
 
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 95822 is Electroencephalogram (EEG); recording in 
coma or sleep only. The definition of code 95909 is Nerve conduction studies; 5-6 studies. The definition of 
code 95886 is 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). The definition of code is 95999 is Unlisted neurological or neuromuscular diagnostic procedure.  
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 procedure codes 95822, 95909, 95886, and 95999. Our 
reviewer says that the medical records do not support the billing of codes 95822, 95909, 95886, and 95999. 
Our reviewer found the records did not support performance of an EEG that meets the baseline technological 
standards for performance of the service (or the use of code 95822). The records did not include a separate 
EEG report with findings of the study. Therefore, this code is not supported.  
 
No nerve conduction study (NCS) was done during the procedure. Rather, triggered EMG was performed for 
testing of pedicle screws. This is considered to be an EMG study (and not an NCS). There was no application 
of an electrical signal to the nerves (on the skin) that was monitored. The coding should have otherwise been 
considered to have been part of the CPT code submitted for an EMG. Code 95909 is not supported in the 
records. 
 
As NCS was not performed (see above), code 95886 would not have been the appropriate code to submit for 
free running and triggered EMG monitoring. 
 
Code 95999 refers to train of four testing. That is generally considered to be a part of the EMG code that is 
submitted. The train of four testing is only done to test the reliability of EMG. It is not otherwise separately 
reimbursible. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 95822, 95909, 95886, and 95999 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 95822, 95909, 95886, and 95999 
provided on February 14, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic colonoscopy provided on April 
14, 2022. 
 
You asked the Plan to waive the copayment for diagnostic colonoscopy. You say that you shouldnt have to 
pay for this. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $350 
copayment for Diagnostic colonoscopies. 
 
You have been asked to pay a $350 copayment for diagnostic colonoscopy. This item/service falls within the 
Diagnostic colonoscopies 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 diagnostic 
colonoscopy provided on April 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic compression device (E0652, E0667).  
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show that the lymphedema extends to the chest, trunk, and/or 
abdomen. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided records do not document that the enrollee has lymphedema extending onto the chest, 
trunk and/or abdomen. Provided records only document bilateral lower extremity lymphedema. As records do 
not document that the enrollee has lymphedema extending onto the chest, trunk and/or abdomen, then it cannot 
be said that the enrollee has unique characteristics that would indicate a segmented pump over a standard 
pump. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve pneumatic compression device (E0652, E0667).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs 
provided on July 12, 2022. 
 
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. You say that you are 
disputing the share cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for Medicare Part B prescription drugs. This item/service falls 
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 coinsurance 
for Medicare Part B prescription drugs provided on July 12, 2022.