Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic procedure (97110) provided on September 
28, 2021. 
 
You asked the Plan to pay for the therapeutic procedure. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says there is a more appropriate CPT code for 
the services rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a PTA shall not be billed as 
services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the 
qualifications of a therapist.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the therapeutic procedure have not been met. Specifically, this claim was billed by a nurse 
practitioner but the records indicate the services were rendered by a physical therapy assistant. It is not 
appropriate for a nurse practitioner to bill for the services of a physical therapy assistant. Therefore, we decided 
that the Plan does not have to pay for the therapeutic procedure (97110) provided on September 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a panitumumab 10mg injection (J9303) 
provided on September 28, 2021. 
 
You asked the Plan to waive the copayment for the panitumumab 10mg injection. You say that the services 
should be covered as you were informed beforehand that the copayment would only be $45. The Plan denied 
your request. The Plan says [Enter plan denial rationale, e.g. "...rules for SNF care have not been met."] 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for the panitumumab 10mg injection (total allowed is 
$5,640.72 x 20% = $1,128.14). Panitumumab 10mg injections fall within the Medicare Part B prescription 
drugs benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for a panitumumab 10mg injection 
(J9303) provided on September 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment received on November 4, 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 the provider is not certified by Medicare.
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are
enrolled in the Medicare program.
The rendering provider is not eligible to bill Medicare. The Plan did not pre-approve the services. We found no
exception that would require the Plan to pay for these items/services. 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 durable medical equipment received on November 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies (99072) and the hot or cold pack therapy (97010) provided on November 5, 2021.
You asked the Plan to pay for codes 99072 and 97010. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
We looked at the file and Medicare rules. Codes 99072 and 97010 have a status code of "B" under the Medicare Physicians Fee Schedule Database (MPFSDB) and no separate payment is made for these codes under the fee schedule as payment is bundled into the payment for the services to which these codes are incident to. Therefore, we decided that the Plan does not have to pay for the additional supplies (99072) and the hot or cold pack therapy (97010) provided on November 5, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from August 21, 2021, to August 22, 2021. 
 You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pay for the services. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there is no documentation for the denied dates 
of service. As such, there is no evidence that these services were medically reasonable, necessary, or even 
provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee from August 21, 2021, to 
August 22, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for aortography (procedure code 75625) provided to the enrollee on 
September 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 that the service is not supported by the records. 
 
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 75625 is "aortography, abdominal, by serialography, radiological supervision and interpretation." 
 
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. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found the documentation supports CPT code 
75625 (aortography, abdominal, by serialography, radiological supervision and interpretation). The procedure 
performed included "Via right femoral approach, ultrasound guidance image archived and stored, and 
aortogram with left extremity runoff." The findings included Normal aorta, renals and iliacs. It is documented 
that a time-out was performed. Sites were prepped and draped. Lidocaine 1% was used over the right common 
femoral. Micropuncture needle was used to enter the vessel under ultrasound guidance. Microwire was placed 
followed by a 6F sheath, then a Bentson wire was placed, followed by an Omniflush catheter. An angiogram 
was performed in the aorta. Per the National Correct Coding Initiative Policy Manual for Medicare Services, in 
regard to the submitted (CPT) code of 75625, A local anesthetic is applied over the common femoral artery. 
The artery is percutaneously punctured with a needle and a guidewire is fed through the artery into the 
abdominal aorta. A catheter is threaded over the guidewire to the point of study and the guidewire is removed. 
Contrast medium is injected and films are taken by serialography, producing a series of individual x-ray films. 
This code reports the radiological supervision and interpretation. 
 
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 have been met. Therefore, we decided that the Plan has to pay for 
aortography (procedure code 75625) provided to the enrollee on September 21, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tertiary level referral for a hematology/oncology 
consultation. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says these services do not need a higher level of care. 
 
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 referral. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found you have bladder cancer, and are stated to have appropriate referrals to oncology and urology within the 
network. There is no documentation that the requested tertiary level provider will offer services that are 
unavailable within the network (such as a clinical trial). The referral is 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 referral have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a tertiary level referral for a hematology/oncology consultation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where he is currently receiving 
care. There are no services available at the LTACH that the enrollee requires that are not available at the health 
care setting being offered by the health plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis. 
 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 long term acute care hospital (LTACH) services.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion with an ophthalmologist to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the OON ophthalmology second opinion. You say that you want another 
opinion from a provider in a different practice. The Plan denied your request. The Plan says it is not medically 
necessary for you to go out-of-network for a second opinion. You have been directed to an in-network provider 
for this service. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 OON ophthalmology second opinion. Our reviewer says that you do not 
meet criteria for an out-of-network second opinion Our physician reviewer found in this case, the record 
indicates that you have a conjunctival hemorrhage.  The record provided is insufficient to establish the medical 
necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the 
coverage criteria are not satisfied.  
 
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 OON ophthalmology second opinion have not been met.  
 
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 the OON ophthalmology second opinion. Therefore, 
we decided that the Plan does not have to pre-approve a second opinion with an ophthalmologist to be provided 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on April 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 code is not paid separately. 
 
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 99135 is "Anesthesia complicated by utilization of 
controlled hypotension (List separately in addition to code for primary anesthesia procedure)." 
 
We find that CPT code 99135 is not supported in the medical record. Specifically, this code has a status 
indicator of "B." This means that this code cannot be paid for separately, and is always bundled into payment 
for other services not specified. 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 anesthesia services 
provided to the enrollee on April 21, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy (EGD) 
with biopsy performed on October 27, 2021. 
 
You asked the Plan to waive the copayment for the EGD with biopsy. You say that the procedure should not be 
billed as outpatient surgery. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for surgical services provided in an outpatient hospital.  
 
Please note that any procedure involving a biopsy or tissue removal is considered surgical. Therefore, you have 
been asked to pay a $200 copayment for the EGD with biopsy. The EGD with biopsy falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy 
(EGD) with biopsy performed on October 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the advanced level name brand hearing aids 
(V5257) provided on September 23, 2021. 
 
You asked the Plan to waive the copayment for the hearing aids. You say that you would like reconsideration 
because the amount the Plan paid on each hearing aid did not meet the allowable amount. The Plan denied your 
request. The Plan says this copayment has been applied correctly. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan contract says 
that you have a $1,625 copay for each Advanced level name brand hearing aid.  
We looked at your request, the file, and the Plan's rules. Based on this information, we decided that the 
copayment that has been applied is correct. You were asked to pay $3,250 for two Advanced level name brand 
hearing aids. Therefore, we decided that the Plan does not have to waive the copayment for the advanced level 
name brand hearing aids (V5257) provided on September 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 10, 2020. 
 
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 the denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the Place of Service (POS) code is generally used 
to reflect the actual setting where the beneficiary receives the face to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the member's face-to-face service was rendered in a laboratory setting. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on 
July 10, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve the services. You say that the enrollee has not met goals and is debilitated 
due to chronic diagnosis. The Plan denied your request. The Plan says the enrollee does not meet the criteria. 
 
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 the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the enrollee does 
not have documented skilled nursing needs (i.e. IVs, complex wound care, new ostomy, new tube feeds). The 
enrollee does not have documented skilled occupational therapy needs.  The enrollee is functioning at a level 
commiserate with a lower level of care (i.e. home exercise program, outpatient therapy, layperson 
assistance). As such, the additional requested home health skilled nursing and home health occupational 
therapy services are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Alginate or other fiber gelling dressing (A6197) provided
on October 19, 2021.
You asked the Plan to pay for code A6197. You say that you would like the Plan to reconsider their denial of
payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that code A6197 has a status code of "P" under the Medicare Physicians Fee Schedule Database
(MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into
the payment for the services to which these codes are incident to. Therefore, we decided that the Plan does not
have to pay for the Alginate or other fiber gelling dressing (A6197) provided on October 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment, spinal (98941) and a 
functional outcomes assessment using a standardized tool (G8942) provided on September 22, 2021, to 
October 18, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for chiropractic manipulative treatment, spinal, and a functional outcomes 
assessment using a standardized tool. You say that the provider called before treatment started and was told 
treatment is covered, except for the initial exam. You also say that when you called, you were told that no 
referral was necessary during the coronavirus (COVID-19). The Plan denied your request. The Plan says you 
do not have out-of-network coverage. 
 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 chiropractic manipulative treatment, spinal 
(98941) and a functional outcomes assessment using a standardized tool (G8942) provided on September 22, 
2021, to October 18, 2021, by an out-of-network (OON) provider.