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

 
We decided that the Plan does not have to pay for procedure code 70480-26 billed for date of service March 12, 
2022. 
 You asked the Plan to pay for procedure code 70480-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 70480-26 is bundled into 
payment for code 70450. 
 
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 
70480-26 is a column II code to column I code 70450. 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 70480-26 billed for date of service 
March 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the respiratory assist device, bi-level pressure 
capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent 
assist device with continuous positive airway pressure device) (E0471) and Humidifier, heated, used with 
positive airway pressure device (E0562) 
 
You asked the Plan to pre-approve the initial trial of a BiPap ASV for central sleep apnea. You say that the 
enrollee's diagnosis does fall under the complex sleep apnea. The Plan denied your request. The Plan says the 
requested services does not meet the criteria found in Medicare LCD 
 
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 initial trial of a BiPap ASV for 
central sleep apnea. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the 
documentation provided does not clearly document: after resolution of the obstructive events, the sum total of 
central apneas plus central hypopneas is greater than 50% of the total apneas and hypopneas, and after 
resolution of the obstructive events, a central apnea-central hypopnea index (CAHI) greater than or equal to 5 
per hour. The review has determined that the records do not support that the services are medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the initial trial of a BiPap ASV for central sleep apnea have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the respiratory assist device, bi-level pressure 
capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent 
assist device with continuous positive airway pressure device) (E0471) and Humidifier, heated, used with 
positive airway pressure device (E0562)
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services billed with codes 75716-XU and 75625 for date of 
service July 13, 2021. 
 
You asked the Plan to pay for codes 75716-XU and 75625. You say that these services were reported 
appropriately for separate payment and are supported in the medical records. The Plan denied your request. The 
Plan says 75625 is not supported as billed, and the payment for 75716 is bundled into the payment for 37228. Although 75716 was billed with a modifier, the records do not support that this service was separate and 
distinct from 37228. 
 
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, thoracic, by serialography, radiological supervision and interpretation. In addition, 
we have confirmed that code 75716 is a column II code to column I code 37228; however, 75716 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 codes 75716-XU and 75625. Our reviewer says that these 
services are not supported with the codes/modifiers billed. Our reviewer found that the operative report does 
not include enough documentation to confirm 76525 has been performed. Per the report, "Utilizing the sheath, 
left lower extremity angiogram performed. A urethral foley catheter advanced to the level of the distal aorta to 
perform the distal aorta angiogram and the aortoiliac angiogram." In this case, CPT 76525 cannot be verified. 
Our reviewer also found that the operative report describes that 75716 was performed in the lower left 
extremity, in addition to revascularization in the same extremity. Therefore, 75716 would be inclusive to 
37228, and is not supported as a separate procedure. Therefore, modifier XU is not supported in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 75716-XU and 75625 have not been met. Therefore, we decided that the 
Plan does not have to pay for services billed with codes 75716-XU and 75625 for date of service July 13, 2021.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay more for the ER visit provided on November 4, 2021. 
 
You asked the Plan to pay more for the ER visit. You say that the provider should have been paid at the 
standard pricing of $791.38 which left an underpayment of $138.46. The Plan denied your request. The Plan 
says that criteria for coverage of CPT code 99285 have not been met. 
 
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. Specifically, the record indicates that the Plan reviewed medical records to 
support the denial. The Plan has not forwarded any medical records and we are unable to determine if the Plan 
was justified in down coding CPT code 99285 to CPT code 99284. It is the burden of the Health Plan to 
substantiate their denial with evidence. In this case, the denial has not been substantiated so we must find in 
your favor. Therefore, we decided that the Plan has to pay more for the ER visit provided on November 4, 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a duplex scan (ultrasound) of lower 
extremity arteries provided on April 8, 2021. 
 
You asked the Plan to waive the deductible for the ultrasound. You say that you were informed that you would 
not be responsible for the charges. The Plan denied your request. The Plan says the correct amount was applied 
to your deductible. 
 
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 $750 deductible which applies to certain items and services.  
 
The ultrasound falls within the benefit category Outpatient Diagnostic Tests and Therapeutic Services and 
Supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 
deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not 
been met at the time the ultrasound was received on April 8, 2021. Therefore, we decided that the Plan does not 
have to waive the deductible for a duplex scan (ultrasound) of lower extremity arteries provided on April 8, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 12, 
2022. 
 You asked the Plan to pay for procedure code 76705. 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 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 
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 billed for date of service March 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the optic nerve imaging provided on March 
29, 2022. 
 
You asked the Plan to waive the copayment for the optic nerve imaging. You say that you have had this 
procedure done before, and you have never been charged a copayment. 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 $5 per 
day copayment for outpatient diagnostic tests.  
 
 
 
 
 
 You have been asked to pay a $5 copayment for a diagnostic test. Optic nerve imaging falls 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 copayment for the optic nerve imaging provided on March 29, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 18, 
2022. 
 
You asked the Plan to pay for procedure code 76705. 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 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 
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 billed for date of service March 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physician's services provided 
on February 11, 2022. 
 
You asked the Plan to waive the copayment for physician's services. The Plan denied your request. The Plan 
says the claim processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for Podiatry Services.  
 
You have been asked to pay a $35 copayment for physician's services. The physician's services falls within the 
Podiatry 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 physician's services 
provided on February 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revascularization of leg arteries for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is a lack of medical necessity. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the record indicates that the enrollee has peripheral artery disease. A request for a left 
femoral popliteal bypass has been submitted. The record provided is insufficient to establish the medical 
necessity of the requested service. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service at this time. 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve revascularization of leg arteries for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says you do not meet Medicare criteria for the requested power 
scooter. 
 The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file does not show that you have a mobility deficit that impairs your participation in MRADLs. The file 
does not show that your condition cannot be improved by a walker, cane, or manual wheelchair.  The file does 
not show that you can safely operate the PMD being requested. This means that Medicare rules for coverage of 
a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the revascularization services (CPT code(s): 37226, 37227, 37225, 
37224). 
 
You asked the Plan to pre-approve the revascularization services. You say that the services are necessary. The 
Plan denied your request. The Plan says that the records do not show that the blockages the enrollee had on the 
ultrasound would cause right side hip and buttock pain. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the revascularization services. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the available documentation supports that the requested revascularization 
services are medically reasonable and necessary for the enrollee in this case. 
 
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 revascularization services have been met. Therefore, we decided that the 
Plan has to pre-approve the revascularization services (CPT code(s): 37226, 37227, 37225, 37224).  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that your care could be managed instead in an alternative setting. 
 
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 pre-approve SNF services. Our reviewer says that 
SNF services are not medically reasonable and necessary. You do not have documented skilled nursing needs. 
You do not have complex wound care needs. You do not have documented skilled therapy needs. You appear 
to be functioning at/near your baseline. Your care needs, custodial and intermittent, can, as a practical matter, 
be provided at a lower level of care. Our physician reviewer found that your condition does not meet Medicare 
criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided on March 4, 2022, 
to March 23, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health services. You say that this provider takes this insurance. 
The Plan denied your request. The Plan says these services from non-participating providers for office visit 
services are not covered under your plan unless they are authorized by the Plan before the services are 
provided. 
 
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 outpatient mental health services provided on 
March 4, 2022, to March 23, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for CGMs and 
related supplies have 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 the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance on March 30, 2022. 
 
You asked the Plan to waive the copayment for ambulance. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost-sharing you are being charged 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 a $225 
copayment for Medicare-covered ambulance transport (one-way). Covered ambulance services include fixed 
wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that can provide care if 
they are furnished to a member whose medical condition is such that other means of transportation could 
endanger the persons health or if authorized by the plan. Non-emergency transportation by ambulance is 
appropriate if it is documented that the members condition is such that other means of transportation could 
endanger the persons health and that transportation by ambulance is medically required. 
 
 
 
 You have been asked to pay a $225 copayment for ambulance. Ambulance falls within the Ambulance 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 ambulance on March 30, 2022.