Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020 and V2025) and lenses (V2100 and 
V2781) provided on December 15, 2021 and December 16, 2021. 
 
You asked the Plan to pay for the frames and lenses. You say that the cost of the three pairs of glasses was only 
$229.80, but you should only be responsible for $29.80. You also say that your husband was advised that as 
long as the cost of the glasses were up to $200.00, you could purchase multiple pairs. The Plan denied your 
request. The Plan says these services exceed the maximum benefit per period. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers 1 pair of lenses and frames every 2 years. 
 
We looked at the file and the Plan's rules. The contract says that you are limited to 1 pair of lenses and frames 
every 2 years. The record shows that you received two pairs of lenses (V2781 x2) and frames (V2025 x2) on 
December 15, 2021, one of each was covered by the Plan, and your lens and frames benefits have been 
exhausted. Based on this information, we decided that the Plan's rules for coverage of the frames and lenses 
have not been met. Therefore, we decided that the Plan does not have to pay for the frames (V2020 and V2025) 
and lenses (V2100 and V2781) provided on December 15, 2021 and December 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on January 8, 
2022. 
 
You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says an appropriate modifier was not 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.  
 
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 the computed 
tomography (CT) scan provided on January 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Alimta (J9305). 
 
You asked the Plan to pre-approve Alimta. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the requested drug is not medically reasonable and necessary. 
 
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 Alimta. Our reviewer says that the 
requested drug, Alimta, is not medically necessary. Our physician reviewer found there was no documentation 
provided that the requested drug, Alimta, meets Medicare criteria for medically reasonable and necessary for 
the enrollee. The reviewer found that the enrollee's creatinine clearance is reported to not be greater than or 
equal to 45 mL/minute. Therefore, the reviewer found that the use of Alimta is not recommended for a 
creatinine clearance less than 45 mL/minute. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Alimta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Alimta (J9305).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy services provided by an occupational 
therapist on January 18, 2021. 
  You asked the Plan to pay for occupational therapy services. You say that the medical records required to 
reprocess the denied claim are attached. The Plan denied your request. The Plan says the code is not 
appropriate for the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that services incident to the professional services of a 
physician or non-physician practitioner is limited to situations in which there is direct supervision of auxiliary 
personnel. Medicare rules say that services of an occupational therapist (OT) billed as services incident to a 
physician/non-physician practitioners service must meet all incident requirements.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of occupational therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner. As such, OT services cannot be paid incident to this provider's professional services. Therefore, 
we decided that the Plan does not have to pay for occupational therapy services provided by an occupational 
therapist on January 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency taxi transportation (A0100). 
 
You asked the Plan to pre-approve additional transportation. You say that you have not shown up for treatment 
since March 26, 2022 due to cancellation of transportation. You also say that you have no support resources to 
get to your treatments, and it is important that you attend to avoid complications. The Plan denied your request. 
The Plan says you have exhausted the established benefit of 24 one-way trips. 
 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 24 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 non-emergency taxi transportation (A0100).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan 
denied your request. The Plan says IRF admission is not medically necessary and you can safely receive the 
services you need in another setting, such as a skilled nursing facility, or at with home with home health 
services or at home with outpatient therapy. 
 
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 that while you have a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program such as an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous implantation of neurostimulator 
electrode array (63650). 
 
You asked the Plan to pre-approve a percutaneous implantation of neurostimulator electrode array. You say 
that the requested services are a medical necessity for you. The Plan denied your request. The Plan says 
medical necessity rules for the requested services have not been met. 
 
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 a percutaneous implantation of 
neurostimulator electrode array. Our reviewer says that the requested services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that detailed documentation is not evident 
regarding trial and failure of recent, reasonable, and comprehensive less invasive conservative care measures to 
include any active physical therapy for the lumbar spine. Additionally, there is no documentation of a 
psychological clearance. You are documented to have an active substance abuse issue. Overall, there is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception to guidelines. 
 
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 percutaneous implantation of neurostimulator electrode array have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a percutaneous implantation of 
neurostimulator electrode array (63650).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the next generation sequencing (NGS) rendered on 
December 7, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that NGS is covered when specific criteria are met. 
 
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 these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has unspecified nutritional 
anemia with a history of chronic kidney disease, iron deficiency anemia, and vitamin B12 deficiency. It is 
noted that the anemia is probably multifactorial. The clinical documentation does not include a cancer 
diagnosis. The documentation does not support that the NGS testing will impact the management and outcome 
of the enrollee in this case. The testing was not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the next generation sequencing (NGS) rendered on December 7, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transesophageal echocardiography (TEE) (93312-59) 
provided on June 10, 2021. 
 
You asked the Plan to pay for TEE. You say that these services were billed appropriately and are separately 
payable. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93312 and 00562. This PTP edit has a modifier indicator of 1, meaning 
modifiers associated with NCCI are allowed. This pair was billed with modifier 59 to bypass the edit; however, the criteria for this modifier are not met and this service is not supported as billed as a distinct or independent 
procedure. 
 
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 93312 is a column II code to column I code 00562; however, 93312 
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 TEE. Our reviewer says that the procedural report does not 
support that the TEE procedure was a separate service from the anesthesia service performed. Our reviewer 
found the procedure report documents "intubated probe insertion: bite block placed, easy TEE probe 
placement, images and procedures utilized for procedural and hemodynamic management and no 
complication". Documentation describes the TEE procedure was performed for anesthesia management, and 
therefore would be inclusive to the anesthesia code reported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TEE have not been met. Therefore, we decided that the Plan does not have to 
pay for transesophageal echocardiography (TEE) (93312-59) provided on June 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from January 29, 2021, 
to February 5, 2021, as billed with Diagnosis Related Group (DRG) 441. 
 
You asked the Plan to pay for inpatient care billed with DRG 441. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 441 is not supported as the diagnosis of metabolic encephalopathy (G93.41) is not supported in the medical record. The 
Plan argues that DRG 442 is more appropriate in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.  
 
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 inpatient care billed with DRG 441. Our 
reviewer says that the diagnosis of metabolic encephalopathy (G93.41) is not supported in the medical record. 
Our physician reviewer found the enrollee presented to the facility following an unwitnessed fall. The 
documentation noted a three-day history of confusion, dizziness, and itching. The enrollee's past medical 
history included hypertension, hyperlipidemia, diabetes mellitus type 2, hypothyroidism, and an aortic 
aneurysm with repair. On admission, the enrollee was noted to be very confused and had an elevated ammonia 
level in the 60's. The enrollee was given a new diagnosis of decompensated liver cirrhosis and was started on 
Lactulose and Rifaximin. The enrollee also underwent a paracentesis during the admission due to large volume 
ascites. The discharge summary indicated a diagnosis of metabolic encephalopathy that was "determined 
hepatic in nature". The physician did not attribute the enrollee's altered mental status to any additional 
underlying metabolic etiology. The review has determined that the medical records did not support the billing 
of metabolic encephalopathy (G93.41). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 441 have not been met. Therefore, we decided 
that the Plan does not have to pay for the inpatient hospital care provided from January 29, 2021, to February 5, 
2021, as billed with Diagnosis Related Group (DRG) 441.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on November 9, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says prior authorization must be obtained for non-emergent services provided by 
an out-of-network provider. 
 
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 the office visit provided on November 9, 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 drug test (G0480) rendered by the out-of-network (OON) 
provider on January 6, 2022. 
 
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 drug test (G0480) rendered by the out-of-network (OON) provider on January 6, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) provided on 
December 2, 2021, by an OON provider. 
 
You asked the Plan to pay for the DME. You say that each of the claims at issue meet Medicare criteria and 
you would like to appeal the denial of the claims for the lack of a prior authorization. The Plan denied your 
request. The Plan says he rendering provider is an OON provider and there was no referral from an in-network 
provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 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 the durable medical equipment (DME) provided 
on December 2, 2021, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the electrocardiogram (93000) provided on 
December 14, 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 service 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 a covered annual physical exam. 
This benefit may not cover some services that your doctor or other health care provider wants you to have. 
Those include lab tests and tests to diagnose or treat a condition. You may have to pay for those tests, even 
when they are done during your annual physical exam. Additionally, enrollees must pay a $25 copayment for 
other Medicare-covered outpatient diagnostic procedures and tests.    
 
You have been asked to pay $16.13 for the Medicare-covered outpatient diagnostic test provided at your annual 
physical exam. This is the Plans allowed amount for this service provided, which is less than the applicable 
copayment. 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 electrocardiogram (93000) provided on 
December 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services provided on December 20, 
2021. 
 
You asked the Plan to pay for the services provided. You say that the claim was billed correctly. The Plan 
denied your request. The Plan says the rules for payment have not been met. 
 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 CPT code 99153 is not supported. Specifically, the code describes the technical component of the 
services provided. 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 the moderate sedation services 
provided on December 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on January 1, 
2022. 
 You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says an appropriate modifier was not 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.  
 
In this case, we have confirmed that code 74176 is a column II code to column I code 74174. This claim has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for the computed 
tomography (CT) scan provided on January 1, 2022.