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

 
We decided that the Plan does not have to pay for a low frequency, non-contact, non-thermal ultrasound 
provided on November 16, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a low frequency, non-contact, non-thermal ultrasound. You say that you are 
appealing with supporting records. The Plan denied your request. The Plan says this provider is not a network 
provider with the Plan. The Plan also says that the services were not referred by a network provider or rendered 
in an in-network facility. The Plan also says that they have also determined that these services are not urgent or 
emergent, nor were they 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 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 a low frequency, non-contact, non-thermal 
ultrasound provided on November 16, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (64633, 64634). 
 
You asked the Plan to pre-approve the ablation procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that therapeutic facet joint procedures are considered 
medically reasonable and necessary for patients who have had two (2) medically reasonable and necessary 
diagnostic facet joint procedures with each one providing a consistent minimum of 80% relief of primary 
(index) pain. 
 
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 ablation procedure. Our reviewer 
says that this procedure is not medically necessary. Our physician reviewer found the records show the enrollee 
has only had one set of diagnostic injections. Coverage rules require two sets of injections. 
 
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 ablation procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a radiofrequency ablation procedure (64633, 64634).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management (E&M) services under code 
99204, provided on March 25, 2022. 
 
You asked the Plan to pay for code 99204. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a new patient is a patient who has not received 
any professional services from the physician or physician group practice within the previous 3 years. 
 
In this case, the enrollee was seen by the same provider on February 28, 2022. This is not a new patient per 
Medicare rules. Therefore, we decided that the Plan does not have to pay for the evaluation and management 
(E&M) services under code 99204, provided on March 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for venography (75822-59) provided on March 28, 2022. 
 
You asked the Plan to pay for venography. You say that the enrollee had multiple exams. The Plan denied your 
request. The Plan says this is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, the record shows that this service was performed as part of the primary procedure rather 
than as a separate service. Based on this information, we decided that Medicare rules for coverage of services 
billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for 
venography (75822-59) provided on March 28, 2022.
Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to pay for 37252. We decided that the Plan does not have to pay for 37253.  
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan says that the denied 
codes are not supported by the medical records submitted. 
 
We decided that the Plan has to pay for 37252.  
 
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 37252 is "intravascular ultrasound (noncoronary vessel) 
during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and 
interpretation; initial noncoronary vessel (List separately in addition to code for primary procedure)." 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 for CPT 37252. Our reviewer says that a review of the 
report documents the use of intravascular ultrasound for the procedure. CPT 37252 can be verified. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
37252.  
 
We also decided that the Plan does not have to pay for 37253. 
 
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 37253 is "intravascular ultrasound (noncoronary vessel) 
during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and 
interpretation; each additional noncoronary vessel (List separately in addition to code for primary procedure)." 
 
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 for CPT 37253. Our reviewer says that there is no 
support for the second billed charge - CPT 37253 - implying a second vessel was analyzed using intravascular 
ultrasound. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 37253 have not been met. Therefore, we decided that the Plan does not have to 
pay for 37253. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the services the enrollee needs can be provided safely in other settings. 
 
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. 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 patient was admitted for surgical management of peritonitis and a colonic mass. The enrollees medical problems are stable. There are no 
complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including 
either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the 
medical record supports a need for 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 patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for IRF care. 
 
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 acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) machine 
you purchased on March 5, 2022. 
 
You asked the Plan to pay for the CPAP machine. You say that you called the Plan and were advised that you 
could purchase the CPAP from an out-of-network provider and be reimbursed for it because network providers 
didn't have CPAP machines in stock. The Plan denied your request. The Plan says you used a provider that is 
not Medicare-certified. The Plan must follow Medicare rules. The rules say that Medicare payment cannot be 
made to a provider that is not enrolled in the Medicare program.  
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Although your Plan allows you to use out-of-network providers, you still have to use providers who 
participate with Medicare.  You chose a provider who is not a Medicare-certified provider. Therefore, we 
decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) machine you 
purchased on March 5, 2022.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
January 2, 2022, to January 31, 2022. 
 
You asked the Plan to pay for home health services. You say that you submitted the Notice of Admission, so 
this claim should be paid. The Plan denied your request. The Plan says the claims history shows that the 
admission date for the first period of care was April 7, 2021.  However, on this bill, you indicated that the 
admission date was April 5, 2021. The admission date data element does not match the first reported period of 
care date. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, [the date you 
entered on this claim as the admission date for the first period of care does not match the date of the first period 
of care as per the claims history. The first claim you billed listed April 7, 2021, as the admission date. 
Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee 
from January 2, 2022, to January 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory drug testing (G0480, 80307) provided on March 
7, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory drug testing. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
 
 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 laboratory drug testing (G0480, 80307) provided 
on March 7, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for occupational therapy on January 04, 2022. 
 
You asked the Plan to waive the copayment for occupational therapy. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says the cost sharing 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 $35 
copayment for Medicare-covered occupational Therapy visits. Covered services include physical therapy, 
occupational therapy, and speech language therapy in-person visits. Outpatient rehabilitation services are 
provided in various outpatient settings, such as hospital outpatient departments, independent therapist offices, 
and Comprehensive Outpatient Rehabilitation Facilities (CORFs). 
 
 
 
 You have been asked to pay a $35 copayment for occupational therapy. Occupational therapy falls within the 
Outpatient rehabilitation services 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 
occupational therapy on January 04, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on January 12, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you never had this test done before 
and you think it should be covered. The Plan denied your request. The Plan says the copayment applied is 
correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $125 
copayment for Medicare covered radiological diagnostic services, not including x-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic).  
 
 
 
 You have been asked to pay $103.23 which is less than the standard $125 copayment for an ultrasound. 
Ultrasounds fall 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 January 12, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visit provided on February 23, 2022. 
 
You asked the Plan to waive the copayment for ER visit. You say that if you would have known how much it 
would cost you would have stayed home. The Plan denied your request. The Plan says the copayment applied 
is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $110 
copayment for each covered emergency room visit.  
 
You have been asked to pay $110 copayment for ER visit. ER visits fall 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 ER visit provided on February 23, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an Emergency Room (ER) visit with 
observation services provided from February 16, 2022, to February 18, 2022. 
 
You asked the Plan to waive the copayment for an ER visit. You say that the copayment should be waived 
because you believe you were admitted to the hospital following your visit. The Plan denied your request. The 
Plan says the copayment applied was 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 $75 
copayment for each emergency room visit. The claim shows that you were in observation and were not 
admitted to the hospital. 
 
You have been asked to pay a $75 copayment for an ER visit. An ER visit 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 an Emergency Room (ER) visit 
with observation services provided from February 16, 2022, to February 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections provided on April 26, 2022. 
 
You asked the Plan to waive the coinsurance for injections. You say that this is an outrageous amount of 
money to have to pay as you already paid copayments. The Plan denied your request. The Plan says the 
coinsurance applied was 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 20% 
coinsurance for Medicare Part B prescription drugs. The allowed amount of this procedure is $154.75, resulting 
in a coinsurance amount of $30.95 ($154.75 x 20% = $30.95). 
 
You have been asked to pay a $30.95 coinsurance for injections. Injections 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 injections provided 
on April 26, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
January 31, 2022. 
 
You asked the Plan to waive the copayment for the PT services. You say that you cannot afford all of the 
copayments. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
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 $35 
copayment for each physical therapy visit.  
 You have been asked to pay a $35 copayment for the PT services. The PT services fall within the Outpatient 
Rehabilitation Services 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 physical 
therapy (PT) services provided on January 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an in-person programming device evaluation (93283) 
provided on May 1, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the in-person programming device evaluation. You say that the services should 
be covered as you disagree with the denial. The Plan denied your request. The Plan says the services denied 
correctly as they were non-emergent and prior authorization was not obtained. 
 
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 an in-person programming device evaluation 
(93283) provided on May 1, 2022 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve the portable oxygen concentrator. You say that the device is medically 
necessary. The Plan denied your request. The Plan says the plan has approved portable oxygen tanks that meet 
the enrollee's needs. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have portable oxygen tanks. The oxygen concentrator serves the same purpose as the 
portable tanks. The records show no reason that the portable tanks would not meet the enrollee's needs. 
Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).