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

 
We decided that the Plan does not have to pay for the intravascular ultrasound of an additional vessel billed 
with code 37253 and the unilateral extremity angiography coded as 75710 for services provided on November 
1, 2021. 
 You asked the Plan to pay for the services as billed. You say that this should be paid as billed. The Plan denied 
your request. The Plan says code 37253 is not supported, and code 75710 is bundled with code 37225. 
 
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)]. 
 
CPT code 75710 is a Column 2 code in relation to code 37225. There is no documentation supporting that this 
angiography was done distinctly from the primary procedure. 
 
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 services as billed. Our reviewer says that code 37253 is 
not supported. Our reviewer found the operative report does not describe an intravascular ultrasound during 
diagnostic evaluation 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 services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the intravascular ultrasound of an additional vessel billed with code 37253 and the 
unilateral extremity angiography coded as 75710 for services provided on November 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxycodone-acetaminophen. 
 
You asked the Plan to pre-approve Oxycodone-acetaminophen. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says Oxycodone-acetaminophen is not covered 
under the enrollee's Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Oxycodone-acetaminophen.  
 
Benefits for Oxycodone-acetaminophen may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a wall-mounted folding shower chair (E0240). 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says that the requested item is not covered because the Plan 
provides coverage for a standard bath chair, which has not been ordered by the provider. 
 
The Plan must follow Medicare rules. Medicare rules say that shower and bath chairs are not covered because 
they are considered hygienic equipment that is not primarily medical in nature. However, the Plan contract 
offers a supplemental benefit for coverage of a bath chair once every 5 years for members who meet medical 
criteria. Additionally, the rules say that Medicare plans must make reasonable and diligent efforts to gather and 
forward information to the Independent Review Entity (IRE).  
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature. However, the Plan provides coverage of a bath chair once every 5 years for 
members who meet medical criteria, as a supplemental benefit. The contract information available in the 
Evidence of Coverage (EOC) booklet does not give specific guidance about what kind of shower chair is 
covered. Additionally, the plan contract does not actually use the language standard when describing the bath 
chairs that are covered, and the medical criteria is not specified. When taking the available information in the 
contract, a folding wall-mounted shower chair would be considered coverable by the language stated. Based on 
this information, we decided that the Plans rules for coverage of this item have been met. Therefore, we 
decided that the Plan has to pre-approve a wall-mounted folding shower chair (E0240).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care visit provided on December 9, 
2021. 
 
You asked the Plan to waive the copayment for urgent care visit. You say that you went to urgent care for your 
booster shot because you thought they were free and was charged for the visit. 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 $40 
copayment for each covered office visit to other providers for urgently needed services.  
 
 
 
 You have been asked to pay $40 copayment for urgent care visit. Urgent care visits fall within the Urgently 
Needed 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 urgent care visit 
provided on December 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for radiology services provided from January 
3, 2022, to January 28, 2022. 
 
You asked the Plan to waive the coinsurance for radiology services. You say that you should have been 
charged $14 copayment each time not 20% coinsurance. The Plan denied your request. The Plan says the 
coinsurance 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 20% 
coinsurance for each Medicare-covered therapeutic radiology service.  
 
 
 
 You have been asked to pay $2,470.80 which is 20% of the allowed amount for radiology services. The 
allowed amount is $12,354.31 (20% x $12,354.31= $2,470.80). Radiology services 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 coinsurance for radiology services provided from January 3, 2022, to January 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar 
spine. 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. 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. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 an MRI of the lumbar spine have been 
met. Specifically, medical records were not provided. Without this documentation, medical necessity is not 
able to be established. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance 
imaging (MRI) of the lumbar spine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre. 
 
You asked the Plan to pre-approve a Freestyle Libre. 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. 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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient mental health care provided from 
October 16, 2021, to October 19, 2021. 
 
You asked the Plan to waive the copayment for inpatient mental health care. You say that you had missed an 
appointment and you were arrested and brought in for treatment so 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 $285 
copayment each day for days 1 through 6.  
 
 
 
 You have been asked to pay $855($285 x 3 days) copayment for inpatient mental health care. Inpatient mental 
health care falls within the Inpatient Mental Health 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 inpatient mental health care provided from October 16, 2021, to October 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest with 
contrast (71260), CT scan of the abdomen and pelvis with contrast (74177), and a bone scan of the whole body 
(78306). 
 
You asked the Plan to pre-approve a CT scan of the chest with contrast, a CT scan of the abdomen and pelvis 
with contrast, and a bone scan of the whole body. You say that the CT scans are medically necessary. The Plan 
denied your request. The Plan says the CT scans are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 a CT scan of the chest with contrast, a 
CT scan of the abdomen and pelvis with contrast, and a bone scan of the whole body. Our reviewer says that a 
CT scan of the chest with contrast, a CT scan of the abdomen and pelvis with contrast, and a bone scan of the 
whole body is not medically necessary. Our physician reviewer found the record indicates that the enrollee has 
a history of adenocarcinoma of the right breast, status post lumpectomy in 1996 and completed radiation in 
2000. She has stable skeletal metastases with no evidence of disease recurrence. CT scans in July 2021 were 
negative for metastatic disease. The provided records do not indicate the medical necessity or reasonableness, 
as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied.  
The requested service cannot be 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 a CT scan of the chest with contrast, a CT scan of the abdomen and pelvis with 
contrast, and a bone scan of the whole body. have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the chest with contrast (71260), CT scan of the 
abdomen and pelvis with contrast (74177), and a bone scan of the whole body (78306).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tecentriq. 
 
You asked the Plan to pre-approve Tecentriq. 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 Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Tecentriq. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the Food and Drug Administration has not 
stated that the requested drug regimen is indicated for the enrollee's condition. The Medicare approved cancer 
drug compendia do not contain a supportive citation for the use of the requested drug regimen in the enrollee's 
clinical situation. No literature from Medicare approved cancer journals that supported the requested regimen 
were submitted for review. The elements of the coverage criteria are not satisfied. The requested service cannot 
be 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 Tecentriq have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Tecentriq.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 15, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service March 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705-26 billed for date of service March 11, 
2022. 
 You asked the Plan to pay for procedure code 76705-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 76705-26 is bundled into 
payment for code 93976. 
 
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 
76705-26 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 procedure code 76705-26 billed for date of service 
March 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 24, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service March 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve the portable ventilator. You say that the ventilator is medically necessary. 
The Plan denied your request. The Plan says coverage rules are not met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 portable ventilator. Our reviewer 
says that the ventilator is not medically necessary. Our physician reviewer found the record indicates that 
BiPAP is to be used at home after hospital discharge. The provided primary source documentation does not 
contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee 
could be treated with a BiPAP machine. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diagnostic peripheral nerve blocks (64417, 64418 
64450). 
 
You asked the Plan to pre-approve the injection services. You say that this is a diagnostic procedure to see if a 
radiofrequency ablation would be beneficial. Please reconsider the decision and approve this procedure. The 
Plan denied your request. The Plan says the records do not show that this injection would be helpful. 
 
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 injection services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the safety and efficacy of peripheral nerve blocks and RFA for shoulder osteoarthritis is unproven.  The request is deemed not medically reasonable or 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 injection services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve diagnostic peripheral nerve blocks (64417, 64418 64450).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a radiation therapy visit provided on 
March 28, 2022. 
 
You asked the Plan to waive the coinsurance for a radiation therapy visit. You say that you should not need to 
pay this coinsurance amount. 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 radiation therapy.  
 
You have been asked to pay a $24.47 coinsurance ($122.37 x 20% = $24.47) for a radiation therapy visit. A 
radiation therapy visit falls within the Radiation Therapy: Radium and Isotope Therapy, Including Technician 
Materials and 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 coinsurance for a radiation 
therapy visit provided on March 28, 2022.