Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the purchase of the Group 3 power wheelchair (PWC) and all related 
accessories provided on November 24, 2021. 
 
You asked the Plan to pay for the Group 3 PWC purchase. You say that this PWC was approved for purchase, 
not a rental. As such, the Plan should pay this claim as billed. The Plan denied your request. The Plan says that 
the fee schedule for these codes do not have an allowed amount for purchase. This PWC can only be billed as a 
rental. As such, this claim was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided a valid denial rationale in this case. Although there 
may be Medicare rules which require rental of PWCs, there is no requirement for Managed Care plans to 
follow these rules. A Managed Care plan may cover a power wheelchair as a purchase. In this case, the 
approval from the Plan dated September 10, 2021, shows that the approval was for a PWC with modifier -NU, 
meaning a purchase. Since the Plan approved this PWC for purchase, it cannot retroactively require the item to 
be rented. We find that the denial of payment for the PWC and accessories is not substantiated. Therefore, we 
decided that the Plan has to pay for the purchase of the Group 3 power wheelchair (PWC) and all related 
accessories provided on November 24, 2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (code G0482) provided on December 8, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for drug testing (code G0482). You say that you were not aware prior authorization 
was needed. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because this provider is out-of-network with the Plan and the ordering physician was also out-of-network with 
the Plan. 
 
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 drug testing (code G0482) provided on December 
8, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (81301) rendered by the out-of-
network (OON) provider on August 26, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal.  The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for 
this service. Therefore, we decided that the Plan does not have to pay for the laboratory service (81301) 
rendered by the out-of-network (OON) provider on August 26, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the needle electromyography services coded 95870 provided 
on January 12, 2021. 
 You asked the Plan to pay for the needle electromyography services. You say that you would like this claim 
reprocessed. The Plan denied your request. The Plan says the use of the modifier is not supported in this case. 
 
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 95870 is a column II code to column I code 95861; however, 95870 
was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the needle electromyography services. Our reviewer says that 
the documentation does not support the use of the 59 modifiers to bypass the edit. Our reviewer found the 
documentation does not support modifier -59, this procedure would be inclusive to CPT 95861. There is no 
documentation to support billing this procedure separately. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the needle electromyography services have not been met. Therefore, we decided 
that the Plan does not have to pay for the needle electromyography services coded 95870 provided on January 
12, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology services provided on July 5, 2020. 
 
You asked the Plan to pay for diagnostic radiology services. The Plan denied your request. The Plan says the 
Plan did not receive a primary carrier's Explanation of Benefits. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment.  Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the 
services and submit a bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has not received 
the primary carrier's Explanation of Benefits. As the secondary insurer, the Plan cannot be held responsible for 
diagnostic radiology services until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for diagnostic radiology services provided on July 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services coded 37184 and 36245 provided on 
August 23, 2021. 
 
You asked the Plan to pay for the medical services as coded. You say that you would like this claim 
reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim as 
billed is not supported in the medical documentation. 
 
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 37184 is Primary percutaneous transluminal mechanical 
thrombectomy, noncoronary, non-intracranial, arterial or arterial bypass graft, including fluoroscopic guidance 
and intraprocedural pharmacological thrombolytic injection(s); initial vessel and the CPT Code Manual 
definition of code 36245 is selective catheter placement, arterial system; each first order abdominal, pelvic, or 
lower extremity artery branch, within a vascular family definition. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the medical services as coded. Our reviewer says that the documentation does not support payment for the services as billed. Our reviewer found that the operative report 
does not include documentation to support pharmacological thrombolytic injection was performed with a 
mechanical thrombectomy. To cite the report "We then performed graft thrombectomy with a graft 
thrombectomy catheter, however we could not fully open the limb. We then created a patch angioplasty with 
bovine pericardial patch by trimming the patch to appropriate size and creating a running anastomosis with 6-0 
prolene, this extended onto the profunda. Once the patch was secured we accessed the patch with a micro 
needle and advanced a microwire into the dacron limb under fluroscopic guidance. We then exchanged up to a 
7 french sheath. We used a glide wire and glide catheter to cross the lesions. Angiogram showed severe 
proximal graft stenosis". In this case CPT 37184 cannot be verified as performed.   
 
 
Regarding CPT code 36245, the operative report does not document selective catheter placement, arterial 
system. In this case, the procedure report does not document this procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medical services as coded have not been met. Therefore, we decided that the 
Plan does not have to pay for the medical services coded 37184 and 36245 provided on August 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for a computed tomography 
(CT) scan of the head/brain. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are numerous participating providers who can render a CT scan of the head/brain. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an out-of-network referral for a computed tomography (CT) scan of the head/brain.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 22, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that this was rendered due to an emergency case. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because this provider is 
out-of-network with the Plan and 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. The record shows that this visit was not provided on an emergency basis. 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 office visit provided on November 22, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on September 27, 2021, by an 
OON provider. 
 
You asked the Plan to pay for physician services. You say that you are appealing this denial. The Plan denied 
your request. The Plan says the services were provided out-of-network and were not 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 physician services provided on September 27, 
2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an outpatient hospital visit provided on 
October 28, 2021. 
 
You asked the Plan to waive the deductible for the outpatient hospital visit. You say that the services should be 
covered as you are on a fixed income and the charges are unreasonable. The Plan denied your request. The Plan 
says the deductible applied correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $395 deductible which applies to Outpatient hospital services.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
hospital services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $395 
deductible which applies to Outpatient hospital services. This cost sharing is a contractual obligation that had 
not been met at the time the outpatient hospital visit was received on October 28, 2021. Therefore, we decided 
that the Plan does not have to waive the deductible for an outpatient hospital visit provided on October 28, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the Oxygen concentrator and inpatient 
hospital care provided from March 19, 2021, to March 23, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the services should be 
covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 
provided. 
 
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 and a $150 copayment per day for 
days 1-5 of Inpatient hospital care.  
You have been asked to pay a 20% coinsurance for an oxygen concentrator (total allowed $132.52 x 20% = 
$26.50) and a $600 copayment for 4 days of inpatient hospital care. 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 inpatient hospital care provided from March 19, 2021, to March 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the scanning computerized ophthalmic 
diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; of the retina 
(92134) and the ophthalmological medical examination and evaluation with initiation or continuation of a 
diagnostic and treatment program (92014) provided on September 7, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
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 $0 copayment for an annual eye exam. 
Additionally, you must pay a $10 copayment for outpatient physician services for the diagnosis and treatment 
of diseases and injuries of the eye, including treatment for age-related macular degeneration and eye 
refractions.  
 
You have been asked to pay a $10 copayment for the vision care services provided. The Plan contract states 
that a $10 copayment is applicable for outpatient physician services for the diagnosis and treatment of diseases 
and injuries of the eye as well as eye refractions. The medical record provided indicates that you received an 
eye refraction on this day as well as diagnostic imaging services. 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 scanning computerized ophthalmic diagnostic imaging, posterior segment, with 
interpretation and report, unilateral or bilateral; of the retina (92134) and the ophthalmological medical 
examination and evaluation with initiation or continuation of a diagnostic and treatment program (92014) 
provided on September 7, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology services provided on  
November 22, 2021. 
 
You asked the Plan to pay for diagnostic radiology services. You say that that the patient was not enrolled in 
hospice until December 23, 2021, which is after the date of service for this claim. The Plan denied your 
request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services 
related or unrelated to the members terminal condition. The Medicare hospice benefit, through fee-for-service 
Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. 
During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or 
discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for diagnostic radiology services provided on 
November 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous carotid artery stenting (PCAS) services. 
 
You asked the Plan to pre-approve PCAS services. You say that this procedure is medically necessary. The 
Plan denied your request. The Plan says this procedure is not covered when the enrollee is not in an approved 
clinical study. 
 
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 PCAS services. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that at issue is the appropriateness and medical necessity of PCAS of this patients 
asymptomatic right internal carotid stenosis. The patient previously underwent carotid endarterectomy for what 
was felt to reflect symptomatic left carotid stenosis. Because clinical studies have not conclusively 
demonstrated the benefit of PCAS in this setting, the patient is required to participate in an approved clinical 
study. Until statistically rigorous studies are completed and confirm clinical efficacy, it is premature to presume 
clinical outcomes and benefit. As such PCAS is not medically necessary in this patient unless it is within the 
confines of an approved clinical study. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PCAS services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous carotid artery stenting (PCAS) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the enrollee would benefit from a CGM. The Plan 
denied your request. The Plan says criteria for this are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
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 assess 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 use insulin 
with at least three daily administrations. The records show that only two set dosages are injected per day. This is not adjusted based on glucose levels. Based on this information, we decided that Medicare rules for coverage 
of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).