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

 
We decided that the Plan does not have to pre-approve placement of a CardioMEMS device (33289, C2624). 
 
You asked the Plan to pre-approve placement of a CardioMEMS device. You say that the requested service is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested service is 
experimental/investigational. 
 
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 placement of a CardioMEMS device. 
Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that there remains a dearth of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of CardioMEMS 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 placement of a CardioMEMS device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve placement of a CardioMEMS device (33289, C2624).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74019 billed for date of service July 27, 
2022. 
 
You asked the Plan to pay for procedure code 74019. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 74019 is bundled into payment for code 74022. 
 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 74019 
is a column II code to column I code 74022. 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 74019 billed for date of service July 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an echocardiography image provided on 
September 16, 2022. 
 
You asked the Plan to waive the copayment for an echocardiography image. You say that you feel this hsould 
be a specialist cost share and not the imaging cost share. 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 $55 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $55 copayment for an echocardiography image. 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 an echocardiography image provided on September 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 95955, 95938, 95939, 95937,95869, and 
95885 billed for date of service July 15, 2022. 
 You asked the Plan to pay for procedure code(s) 95955, 95938, 95939, 95937,95869, and 95885. You say that 
you disagree with the denial. The Plan denied your request. The Plan says this code is included in the skilled 
nursing facility payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the SNF for its Part A inpatients and are not separately payable. 
 
The records indicate that this service was provided to the enrollee while a SNF inpatient. Per the Physician Fee 
Schedule, CPT codes 95955, 95938, 95939, 95937,95869, and 95885 have a Professional/Technical indicator 
of 1. This means that CPT codes 95955, 95938, 95939, 95937,95869, and 95885 have both a professional and 
technical component. In this case, CPT codes 95955, 95938, 95939, 95937,95869, and 95885 have not been 
billed with an appropriate modifier to indicate the professional component. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 95955, 95938, 95939, 95937,95869, and 95885 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code(s) 95955, 
95938, 95939, 95937,95869, and 95885 billed for date of service July 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on May 6, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. 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 $150 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
You have been asked to pay $136.39, which is less than the $150 copayment for an ultrasound. 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 an ultrasound provided on May 6, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orencia. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has rheumatoid arthritis 
with rheumatoid factor of multiple sites without organ or system involvement. She has not tried and failed the 
Plan's required drugs, Inflectra, Remicade, or Simponi Aria. The records do not show that the required drugs 
would be contraindicated or less effective; therefore, Orencia is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Orencia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deluxe eye frames (V2025), progressive lenses (V2781), 
anti-reflective coating (V2750), and polycarbonate lenses (V2784) provided on September 13, 2022. 
 
You asked the Plan to pay for deluxe eye frames (V2025), progressive lenses (V2781), anti-reflective coating 
(V2750), and polycarbonate lenses (V2784). You say that you needed new lenses to see and operate a vehicle 
safely. The Plan denied your request. The Plan says per your 2022 EOC, you are responsible for any amount 
over the $100 retail price. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when cover up to $100 (combined in and out-of-network) benefit 
toward the purchase and fitting of eyeglasses and pair of lenses. The record shows this benefit was exhausted 
with this service. 
 
We looked at the file and the Plan's rules. The Plan rules say that you pay any amount over $100 retail price for 
the purchase and fitting of eyeglasses and pair of lenses or contact lenses (1 per calendar year). Based on this 
information, we decided that the Plan's rules for coverage of deluxe eye frames (V2025), progressive lenses 
(V2781), anti-reflective coating (V2750), and polycarbonate lenses (V2784) have not been met. Therefore, we 
decided that the Plan does not have to pay for deluxe eye frames (V2025), progressive lenses (V2781), anti-
reflective coating (V2750), and polycarbonate lenses (V2784) provided on September 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628,64629). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 an Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there are multiple plausible pathologic sources of significant pain generation. 
The low back pain, the noted pain-aggravating factors (bending backward, bending forwards, bending 
sideways, and standing), the diminished flexion and extension, and an intact strength exam were/are all non-
specific to any pathologic entities. Documentation is lacking regarding reasonably detailed and/or evidenced 
findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of the 
enrollees chronic persistent pain. The available documentation does not support actual formal surgical ablation 
of pre-designated basivertebral nerves as being medically necessary and/or reasonable at this time. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628,64629).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services for anesthesia for percutaneous image-
guided injection, drainage or aspiration procedures on the spine or spinal cord; lumbar or sacral (code 01938) 
provided on April 26, 2022. 
 
You asked the Plan to pay for physician's services for anesthesia for percutaneous image-guided injection, 
drainage or aspiration procedures on the spine or spinal cord; lumbar or sacral. The Plan denied your request. 
The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on May 8, 2022 and May 9, 2022. Comparison of the claims shows these are exact duplicates. 
There is no evidence presented to support that the billed services were provided twice on the same date. Based on this information, we decided that the Medicare rules for physician's services for anesthesia for percutaneous 
image-guided injection, drainage or aspiration procedures on the spine or spinal cord; lumbar or sacral have not 
been met. Therefore, we decided that the Plan does not have to pay for physician's services for anesthesia for 
percutaneous image-guided injection, drainage or aspiration procedures on the spine or spinal cord; lumbar or 
sacral (code 01938) provided on April 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote patient monitoring services provided on March 17, 
2022. 
 
You asked the Plan to pay for remote patient monitoring services. You say that you are appealing the claim 
payment denial. 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 remote patient 
monitoring services provided on March 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64493 and 64494 billed for date of service 
June 9, 2022. 
 
You asked the Plan to pay for procedure code 64493 and 64494. You say that this should be paid for. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.   
In this case, the MUE for CPT code 64493 and 64494 is 1. The MAI value for these codes is 2. You billed 2 
units of these codes, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage of procedure code 64493 and 64494 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 64493 and 64494 billed for date of service June 9, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 27, 2022, 
to May 27, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the claim has not been billed 
with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 27, 2022, to 
May 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is necessary because the enrollee 
had surgery to amputate one of his legs. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary. 
 
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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee may need physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve the IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lenses fitting provided on September 15, 2022. 
 
You asked the Plan to pay for the contact lenses fitting. You say that you had a regular eye exam and renewed 
an existing prescription for contact lenses. You say this should be covered as a part of the regular eye exam. 
The Plan denied your request. The Plan says the service is not a covered benefit. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan does not cover contact lenses fittings. 
 
We looked at the file and the Plan's rules. Specifically, the service is not a covered benefit. Based on this 
information, we decided that the Plan's rules for coverage of the contact lenses fitting have not been met. 
Therefore, we decided that the Plan does not have to pay for the contact lenses fitting provided on September 
15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services you need can be safely provided in other settings for example, a skilled 
nursing facility, home with home health services, or home with outpatient therapy. 
 
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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that based on the medical records provided the complexity of the patient's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patients medical conditions appear improved on stable medications with 
no issues that appear to require a physicians evaluation three or more times per week in a hospital setting. The 
records do not explain why the intensive inpatient rehabilitation therapy program is necessary and why therapy 
at a lower level of care such as in a skilled nursing facility is not appropriate for the patient. There is concern 
that the patient will not be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an inpatient rehabilitation facility due to his reported weakness, shortness of breath, 
fatigue and oxygen desaturations with therapy. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services {{enter specific services at issue}} 
provided on June 6, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for inpatient hospital services. You say that the records attached support these 
services. The Plan denied your request. The Plan says there is no preauthorization on file for the services 
provided. 
 
 
 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 inpatient hospital services {{enter specific 
services at issue}} provided on June 6, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for principal care management visit provided on August 18, 
2022. 
 
You asked the Plan to pay for principal care management visit. You say that services rendered at a nursing 
facility and the provider is the only cardiologist available. 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 principal care 
management visit provided on August 18, 2022.