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

We decided that the Plan has to pre-approve myocardial perfusion imaging (78452).
You asked the Plan to pre-approve myocardial perfusion imaging. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that cardiovascular nuclear imaging is covered under specific circumstances. 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 myocardial perfusion imaging. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has multiple risk factors for coronary artery disease (CAD) as well as known established vascular disease in the carotid and vertebrobasilar arteries and a prior cerebrovascular accident (CVA). He now presents with increasing exertional intolerance and fatigue which can be an anginal equivalent in the elderly. Based on his markedly elevated risk and his current anginal type symptoms, he meets the coverage criteria for cardiac nuclear stress evaluation to rule out ischemia as a cause of his symptoms. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of myocardial perfusion imaging have been met. Therefore, we decided that the Plan has to pre-approve myocardial perfusion imaging (78452).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) and supplies 
provided to the enrollee on January 13, 2021. 
 
You asked the Plan to pay for the CGM and supplies. You say that this was medically necessary for the 
enrollee. The Plan denied your request. The Plan says that criteria for coverage have not been met.  
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not require 
frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this 
information, we decided that Medicare rules for coverage of the CGM and supplies have not been met. 
Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) and 
supplies provided to the enrollee on January 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services you received on May 9, 
2021. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that since you were admitted 
to the hospital, there should not be a separate copayment for the ambulance services. The Plan denied your 
request. The Plan says you were charged this copayment 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 $125 
copayment for ambulance services.  
 
You have been asked to pay a $125 copayment for the ambulance services. This copayment applies regardless 
of whether or not you are admitted to the hospital. 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 
ambulance services you received on May 9, 2021.
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. 
 
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 your nursing, medical management, and rehabilitation needs do not 
require an interdisciplinary team approach to delivery of rehabilitation care. 
 
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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for leg pain and drainage from 
surgical site from recent repair of hip fracture. Your medical problems are stable. There are no complex nursing 
or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a 
need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found 
that your 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.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound coded 76700 provided on July 19, 2021. 
 
You asked the Plan to pay for the ultrasound. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76700 
for the ultrasound is a column II code to column I code 93976. 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 ultrasound coded 76700 provided on July 
19, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a Nerve Block Procedure (64510).
You asked the Plan to pre-approve the Nerve Block Procedure. You say that the procedure is medically
necessary. The Plan denied your request. The Plan says that this procedure is not supported for this application.
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 pre-approve the Nerve Block Procedure. Our
reviewer says that the requested services are considered medically reasonable and necessary in this case. Our
physician reviewer found the Administration has approved this therapy for treatment resistant PTSD.
It is clearly established therapy for PTSD. The requested Stellate Ganglion block is medically reasonable and
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 the Nerve Block Procedure have been met. Therefore, we decided that the Plan
has to pre-approve a Nerve Block Procedure (64510).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on February 11, 2020. 
 
You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-
contracted providers at the preferred provider rate if services are not available from preferred providers. You 
say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your 
request. The Plan says the code is not appropriate for the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physical therapy services have not been met. Specifically, the medical records for the visit 
provided on February 11, 2020 were not provided. This means that we cannot determine if Medicare coverage 
criteria has been met or if payment is due. Therefore, we decided that the Plan does not have to pay for physical therapy services provided on February 
11, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Prolia.
You asked the Plan to pre-approve the Prolia. You say that you would like reconsideration because this drug is
medically necessary. The Plan denied your request. The Plan says that there is no documentation in the records
that the member is taking Vitamin D and calcium.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA approved
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Prolia. Our reviewer says that the
requested medication is FDA-approved for the enrollee's diagnosis. Our physician reviewer found per the
Osteoporosis Pharmacotherapy In Postmenopausal Women Treatment Recommendation, T-score between -1
and -2.5 if the FRAX(R) 10-year probability for major osteoporotic fracture is 20% or greater or the 10-year
probability of hip fracture is 3% or greater in the U.S.
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 Prolia have been met. Therefore, we decided that the Plan has to preapprove
Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for oxygen equipment (E0431, E1390) 
provided on June 19, 2021. 
 
You asked the Plan to waive the coinsurance for oxygen equipment. You say that you cannot afford to pay, and 
you are on a fixed income. The Plan denied your request. The Plan says the coinsurance applied correctly based 
on the allowed amounts. 
 
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 Durable medical equipment (DME) and related supplies.  
 
 
 You have been asked to pay a 20% coinsurance for oxygen equipment (20% of $125.13 = $25.03 and 20% of 
$22.55 = $4.51 for a total copayment of $29.54). Oxygen equipment falls within the Durable medical 
equipment (DME) and related 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 coinsurance 
for oxygen equipment (E0431, E1390) provided on June 19, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on 
June 8, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you went to the ER because you had 
no choice.  You stated that the network urgent care facilities did not have the equipment needed for your visit. 
The Plan denied your request. The Plan says you were charged this copayment 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 room services.  
 
You have been asked to pay a $90 copayment for the ER visit. This copayment applies regardless of the reason 
for the ER visit. 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 the emergency room (ER) visit you had on June 
8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation provided on July 13, 
2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that the previous provider was 
charging for unnecessary services and you did not want to be aligned with them as a patient. You say that this 
provider did a cleaning as a new patient and the initial visit should be paid. The Plan denied your request. The 
Plan says a comprehensive oral evaluation is only covered once every three years. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of 
one comprehensive oral evaluation every three plan years. The Plan paid for the comprehensive oral evaluation 
provided on January 21, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have 
to pay for the comprehensive oral evaluation provided on July 13, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 22 home health physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 22 home health PT visits. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 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 22 home health PT visits. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the records do not show that 
skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve 
your condition, or to establish/perform a maintenance program to maintain your condition and/or prevent 
deterioration. The records do not show that skilled therapy services are required to effectively provide 
treatment, care, and/or services in order to improve your level of function, or to establish/perform a 
maintenance program to maintain your level of function and/or prevent deterioration. You appear to have 
reached a plateau in improvement with current treatment and should be able to perform home exercises without 
supervision as they have completed 38 sessions already for their condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 22 home health PT visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 22 home health physical therapy (PT) visits.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (76700) provided on July 12, 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 76700 is a column II code to column I code 93976. 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 (76700) provided on July 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transesophageal echocardiogram (TEE) rendered on July 
22, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that any ICD-10 diagnosis code not listed under the ?ICD-
10 Codes that Support Medical Necessity? section of this article does not support medical necessity for 
procedure code 93312. 
 
We looked at the file and Medicare rules. The file shows that procedure code 93312 (TEE) was billed with 
diagnosis code I48.91. This diagnosis is not listed as one supporting medical necessity for 93312 and is 
therefore not covered. Therefore, we decided that the Plan does not have to pay for the transesophageal 
echocardiogram (TEE) rendered on July 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services provided on March 8, 2021. 
 
You asked the Plan to pay for the moderate sedation services. You say that the procedure was rendered in the 
appropriate place of service. You say that the claim should be reviewed and reconsidered for payment. The 
Plan denied your request. The Plan says the provider did not bill as required by Medicare coding regulations. 
  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99153 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service). 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, CPT code 99153 is a 
technical component only code. The technical component will not be paid to the physician when performed in a 
facility setting. This means that payment for this service is the responsibility of the facility to any vendor. 
Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have 
not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services 
provided on March 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services provided by an occupational 
therapist on March 1, 2021. 
  You asked the Plan to pay for the occupational therapy services. You say that plans are required to pay non-
contracted providers at the preferred provider rate if services are not available from preferred providers. You 
say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your 
request. The Plan says the records do not support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that services of an occupational therapist billed as 
services incident to a physician/non-physician practitioner's service must meet all incident requirements.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the occupational therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner. As such, occupational therapy services cannot be paid incident to this provider's professional 
services. Therefore, we decided that the Plan does not have to pay for occupational therapy services provided 
by an occupational therapist on March 1, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services (procedure code 76705) provided to the 
enrollee on July 21, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this was not billed with the appropriate modifier. 
 
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 76705 is "Ultrasound, abdominal, real time with image 
documentation; limited (eg, single organ, quadrant, follow-up)." 
 
We find that CPT code 76705 is not supported in the medical record. Specifically, this code cannot be reported 
separately without the appropriate modifier. 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 
imaging services (procedure code 76705) provided to the enrollee on July 21, 2021.