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

 
We decided that the Plan does not have to pay for procedure code 76942 billed for date of service May 11, 
2022. 
 
You asked the Plan to pay for procedure code 76942. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 76942 is bundled into 
payment for code 36556. 
 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 76942 
is a column II code to column I code 36556. 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 76942 billed for date of service May 11, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve out-of-network services. 
 
You asked the Plan to pre-approve out-of-network services. You say that in-network providers do not have the 
expertise to evaluate, diagnose and treat the rare complex combination of pulmonary, immune system issues 
and infection diseases you are suffering. You say that the specialists treating you state that you need more 
sophisticated testing and treatment that is most commonly done by the team of specialists at the out-of-network 
hospital. The Plan denied your request. The Plan says that in-network specialists are available. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
 
  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 out-of-network services. Our reviewer 
says that evaluation at the out-of-network provider is considered reasonable and medically necessary. Our 
physician reviewer found that you have a persistent and complex series of pulmonary problems that would 
benefit from the unique expertise in respiratory diseases at the out-of-network provider. You have features of 
bronchopulmonary aspergillosis, findings suggestive of invasive aspergillosis with recovery of the organism at 
bronchoscopy and worsening of imaging findings when treated with steroids. The specialists currently caring 
for you request a consultation at the out-of-network provider because they have the most extensive experience 
in the world with unusual and difficult to manage pulmonary conditions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of out-of-network services have been met. Therefore, we decided that the Plan has 
to pre-approve out-of-network services.  
 
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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee is receiving medically necessary acute 
and/or critical care. The enrollee does not have clinical conditions that cannot be appropriately treated in the 
current hospital, and there are no issues for which LTACH may offer a therapeutic advantage. 
 
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 transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility is recommended 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 9, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on May 5, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that there is no agreement that the codes billed 
are included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay 
for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 5, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device and garments (E0652, 
E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the requested device and 
garments are medically necessary for the enrollee. The Plan denied your request. The Plan says the clinical 
information submitted does not show that the enrollee failed a reasonable trial of a basic pump prior to 
requesting the advanced pump. The notes do not show that the enrollee had at least four weeks of regular, 
daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision 
by a technician who is skilled in and who successfully uses the pump. The request for the advanced pneumatic 
compression device and leg garments does not meet the medical necessity criteria. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
and garments (E0652, E0667).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a phlebectomy (37766). 
 
You asked the Plan to pre-approve the phlebectomy. You say that the procedure is medically necessary. The 
Plan denied your request. The Plan says that coverage rules have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a phlebectomy is covered when 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 phlebectomy. Our reviewer says 
that the requested procedure is medically necessary. Our physician reviewer found the patient has evidence of 
enlarged tortuous varicose veins that the provider articulates is not related to saphenous reflux. There is 
adequate documentation that a thorough workup for the patients leg pain has been performed, including 
documentation of normal arterial perfusion. There is also documentation from another provider indicating that 
symptoms are coming from the varicose veins as opposed to other potential etiologies such as lumbar spine.  
 
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 phlebectomy have been met. Therefore, we decided that the Plan has to pre-
approve a phlebectomy (37766).  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the emergency room services provided on June 
30, 2022. 
 
You asked the Plan to waive the copay for the services provided. You say that you should not have to pay the 
copay. 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 $50 
copay for emergency care.  
 
We looked at the file and the rules. The file does not show that you were admitted to the same hospital where 
you received the emergency room services. You have been asked to pay a $50 copay for the services provided. 
The services 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 copay for the emergency room services provided on June 30, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a colonoscopy, flexible; with biopsy, single or multiple 
(CPT 45380). 
 
You asked the Plan to pre-approve a colonoscopy, flexible; with biopsy, single or multiple. You say that a 
colonoscopy, flexible; with biopsy, single or multiple is medically necessary. The Plan denied your request. 
The Plan says the enrollee does not have a risk factor that requires a screening colonoscopy more frequently 
than every 10 years. The doctor's note indicates that the last colonoscopy was normal 5 years ago. 
 
The Plan follows Medicare rules. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a colonoscopy, flexible; with biopsy, 
single or multiple. Our reviewer says that a colonoscopy, flexible; with biopsy, single or multiple is not 
medically necessary. Our physician reviewer found document provided notes that enrollees prior colonoscopy 
5 years earlier was normal and that the enrollee denied red flag signs or symptoms, and that enrollee has no 
family history of colon cancer. The records provided support that the enrollee does not meet LCD L34213 nor 
CMS chapter 15 criteria, and thus is not characterized as a High Risk individual to warrant as medically 
necessary a repeat "screening" colonoscopy at the requested 5-year interval. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a colonoscopy, flexible; with biopsy, single or multiple have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a colonoscopy, flexible; with biopsy, single 
or multiple (CPT 45380).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for additional acupuncture visits. 
 
You asked the Plan to provide coverage for additional acupuncture visits. You say that you suffered a sprained 
ankle in March and you were told by your acupuncturist that your ankle is still swollen and that you will need 
additional acupuncture treatments. The Plan denied your request. The Plan says you have used all 24 
acupuncture visits this year. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plans rules apply in this case.  
 
We looked at the file and the Plans rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the file shows that you have exhausted the 
acupuncture benefit for this year. Therefore, we decided that the Plan does not have to provide coverage for 
additional acupuncture visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have been in the hospital for 12 days and is not 
able to walk currently. You are not ready to go home and are unable to care for yourself. With rehab you will 
be able to get stronger and be able to manage your daily activates. The Plan denied your request. The Plan says 
the criteria for admission to the Acute Inpatient Rehabilitation setting have not been met. Your ongoing skilled 
therapy and nursing needs can be provided at a lower level of 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. Our physician reviewer found your medical problems are stable and there are no complex nursing or rehabilitation 
needs. There is no documented need for intensive rehabilitation services and medically necessary care can be 
provided in a different level of 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 31, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the documentation does not support the 
services as 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 there is insufficient information in the record to determine if Medicare rules for coverage of the laboratory services have been met. 
Based on this information, we decided that there is insufficient information in the record to determine if 
Medicare rules for coverage of the laboratory services provided on have been met. The provider did not send 
records to support that the testing was performed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on January 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the interspinous spacer procedure. 
 
You asked the Plan to pre-approve the interspinous spacer procedure.. You say that this procedure is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested interspinous 
spacer surgery 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 the interspinous spacer procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the interspinous spacer devices remain experimental. More research is 
needed before coverage can be approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the interspinous spacer procedure. have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the interspinous spacer procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Power wheelchair, group 3 standard, single power 
option, sling/solid seat/back, patient weight capacity up to and including 300 pounds K0856 with Wheelchair 
accessory, power seating system, tilt only (E1002) battery (E2361) manual swing away, retractable or 
removable mounting hardware for joystick, other control interface, or positioning accessory (E1028) headrest 
(E0955) adjustable footplate (K0040) skin protection and positioning wheelchair seat cushion (E2607) 
removable headrest hardware (E1028) privacy flap (k0108) calf pad (K0108). 
 
You asked the Plan to pre-approve the power wheelchair. You say that you feel this was an invalid denial as the 
enrollee has a diagnosis of amyotrophic lateral sclerosis. The Plan denied your request. The Plan says the 
enrollee does not have medical need for single power option included with K0856 group 3 power wheelchair. 
A privacy flap does not serve a medical need and cannot be approved. Calf pads are already included with the 
wheelchair and cannot be approved 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is able to dress and groom with set-up and is independent with feeding. 
The enrollee has upper body strength and control to utilize standard controls. A single power option is not 
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 the power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Power wheelchair, group 3 standard, single power option, sling/solid seat/back, 
patient weight capacity up to and including 300 pounds K0856 with Wheelchair accessory, power seating 
system, tilt only (E1002) battery (E2361) manual swing away, retractable or removable mounting hardware for 
joystick, other control interface, or positioning accessory (E1028) headrest (E0955) adjustable footplate 
(K0040) skin protection and positioning wheelchair seat cushion (E2607) removable headrest hardware 
(E1028) privacy flap (k0108) calf pad (K0108).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the elbow repair assistant surgery services coded as 24357-
AS provided on December 2, 2021. 
 
You asked the Plan to pay for the elbow repair assistant surgery services. You say that you would like this 
claim reprocessed and approved for payment. The Plan denied your request. The Plan says the record does not 
show that the provider of the surgical assistant services is a physician, physician assistant, nurse practitioner, or 
clinical nurse specialist. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the elbow repair assistant surgery 
services coded as 24357-AS provided on December 2, 2021.