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

 
We decided that the Plan does not have to pre-approve MyoPro, powered upper extremity range of motion 
assist device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the MyoPro is a covered device within the 
DME benefit category under Original Medicare. The Plan denied your request. The Plan says MyoPro is 
unproven and not medically necessary due to insufficient clinical evidence of safety and/or efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
 
 
 
 
 
 
 
 We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve MyoPro, powered upper extremity range of motion assist device (L8702).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 12, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that most in-network providers cannot perform 
the complex drug testing that you provide. The Plan denied your request. The Plan says the rendering provider 
is an out-of-network provider and there was no referral from an in-network provider or an approved 
authorization. Also, the services 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 laboratory services provided on October 12, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the collagenase, clostridium histolyticum 
injection (J0775) provided on October 18, 2021. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for chemotherapy drugs and a 20% coinsurance for all other drugs covered under Medicare Part B. 
 
 You have been asked to pay $1,070.87 (Plan allowed amount of $5,354.37 x 20% coinsurance) for the 
Medicare Part B drug injection provided. 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 the 
collagenase, clostridium histolyticum injection (J0775) provided on October 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray examinations of the hands (73130 x 2) and the  
x-ray examinations of the feet (73630 x 2) rendered by the out-of-network (OON) provider on May 14, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal.  The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay 
for these services. Therefore, we decided that the Plan does not have to pay for the x-ray examinations of the 
hands (73130 x 2) and the x-ray examinations of the feet (73630 x 2) rendered by the out-of-network (OON) 
provider on May 14, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the vascular surgery services provided on September 28, 2021, billed 
with codes 36565-LT, 36565-76-59-LT, and 77001-26-59. 
 
You asked the Plan to pay for the surgical services provided. You say that this should be paid. The Plan denied 
your request. The Plan says that this procedure was not correctly billed for a bilateral procedure. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided a valid denial rationale in this case. The claim was 
denied due to Medically Unlikely Edits; however, the use of modifier -76 explains that this same procedure had 
to be repeated on a different site, which is supported by the operative report. The appeal denial rationale is that 
this was not correctly reported for a bilateral procedure, but the coding and records show tat this was not a 
bilateral procedure but involved placing a catheter in a separate vein on the same side. In addition, no rationale 
was given for the denial of code 77001. Without a a valid rationale for the codes at issue, we find that the Plan's 
decision is not supported. Therefore, we decided that the Plan has to pay for the vascular surgery services 
provided on September 28, 2021, billed with codes 36565-LT, 36565-76-59-LT, and 77001-26-59.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine disposable supplies (A0382) provided on May 29, 
2021. 
 You asked the Plan to pay for the routine disposable supplies. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says CPT code A0382 is not separately 
billable. 
 
The Plan must follow Medicare rules. Medicare rules say that payment under the fee schedule for ambulance 
services includes routine supplies. 
 
We find that CPT code A0382 is not supported in the medical record. Specifically, payment for the routine 
supplies is included in the payment for the ambulance services. CPT code A0382 is not separately 
reimbursable. Based on this information, we decided that Medicare rules for coverage of the routine disposable 
supplies have not been met. Therefore, we decided that the Plan does not have to pay for the routine disposable 
supplies (A0382) provided on May 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state (92015) provided 
November 30, 2021. 
 
You asked the Plan to pay for the eye refraction. You say that this service was necessary. The Plan denied your 
request. The Plan says eye refractions are only covered as part of a routine eye exam.  
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 these services when provided during a routine exam. 
 
We looked at the file and the Plan's rules. In this case the eye refraction was provided as part of a medical eye 
exam. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not 
been met. Therefore, we decided that the Plan does not have to pay for the determination of refractive state 
(92015) provided November 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services you received on 
September 2, 2021. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you called the nurse line 
out of concern for medication prescribed to you for multiple wasp stings.  This should qualify for authorization 
of this service. The Plan denied your request. The Plan says you were charged this copayment 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 $250 
copayment per trip for ambulance services.  
 
You have been asked to pay a $250 copayment for the ambulance services. This copayment applies regardless 
of the reason for the service. 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 services you 
received on September 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure 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 medical studies have not proven that this procedure is 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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation is not evident regarding any significant objective findings on 
examination. The CT dated 1/18/19 was not provided for review. It was noted (on the 11/16/21 exam) to show, 
advanced degenerative endplate changes present at the L3-4 level, significant endplate sclerosis, anterior bulky 
osteophyte formation, significant loss of intervertebral distance also noted at the L1-2 and L2-3 levels. This 
does not corroborate Modic changes at all of the requested procedural levels. Additionally, the exam from 
11/16/21 was non-specific to any pathologic entities. Overall, documentation was/is lacking regarding 
reasonably detailed and/or evidenced findings supportive of the spinal vertebral bodies as being the 
overwhelming primary generators of the enrollees chronic persistent pain. The documentation does not support actual formal surgical ablation of pre-designated basivertebral nerves as being medically necessary 
and/or reasonable at this time. 
 
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 the Intracept procedure for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve superior capsular reconstruction (29826, 29827) for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered investigational. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is a lack of large volume, long-term peer-reviewed outcome studies to support the use of superior 
capsular reconstruction as an effective treatment. Additionally, detailed documentation is not evident regarding 
trial and failure of recent, reasonable, and comprehensive less invasive conservative care measures. There was 
no evidence of any extenuating circumstances in this patient's specific case either. Therefore, the request for 
superior capsular reconstruction would not be 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve superior capsular reconstruction (29826, 29827) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (72141) provided on May 22, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service.  
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 72141 
is a column II code to column I code 72142. 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 services (72141) provided on May 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy services provided on 
October 27, 2021. 
 
You asked the Plan to waive the copayment for the physical therapy services. You say that the services should 
be covered as you called the Plan beforehand and were advised the provider was in-network. The Plan denied 
your request. The Plan says the cost-sharing applied correctly based on the services provided, there is no record 
of you calling the Plan beforehand to verify the providers network status and that the copayment would be the 
same regardless of their network status. 
 
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 
copayment for Outpatient rehabilitation services.  
 
 
  You have been asked to pay a $20 copayment for physical therapy services. Physical therapy services fall 
within the Outpatient rehabilitation 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 physical therapy services provided on October 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing (0242U) provided on April 17, 2021. 
 
You asked the Plan to pay for Guardant360 testing. You say that this was billed correctly. The Plan denied your 
request. The Plan says this was not billed with the correct POS. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Guardant360 testing have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for Guardant360 testing (0242U) provided on April 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medication assisted treatment provided on May 31, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the medication assisted treatment. You say that you were told no authorization 
was needed in network and you are requesting services to be paid prior to being enrolled. The Plan denied your 
request. The Plan says the rendering provider was an out-of-network provider and there was no referral from 
the enrollee's primary care physician. 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 a medication assisted treatment provided on May 
31, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 
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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services. 
You may benefit from skilled occupational therapy (OT) services. The documentation does not support that it is 
medically reasonable and necessary to provide these skilled nursing or skilled therapy services (or a 
combination of these services) on a daily basis on an inpatient basis, in a skilled nursing facility setting. 
 
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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services, pharmaceutical services, gastrointestinal 
services, office visits, specialty services, therapeutic services, and a telephone evaluation and management 
service provided on August 3, 2021, to September 28, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services, pharmaceutical services, gastrointestinal services, office 
visits, specialty services, therapeutic services, and a telephone evaluation and management service. You say that when you spoke to the Plan during your enrolling, you and the agent called over to the medical clinic and 
asked for sure if they accepted the Plan and you were both informed that they did. You also say that you are 
now getting medical bills from the provider that you cannot afford and now you feel like you cannot go see 
your provider when need be. The Plan denied your request. The Plan says per eligibility at the time of initial 
enrollment on April 15, 2021, the member provided a primary care physician (PCP), which was invalid due to 
the provider being out of network with the Plan. The Plan also says that the PCP was updated based on the 
member's zip code on April 20, 2021, and a letter was generated to inform the member that the primary care 
physician was updated. 
 
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 record shows that requested providers in this case are not network providers 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 laboratory services, pharmaceutical 
services, gastrointestinal services, office visits, specialty services, therapeutic services, and a telephone 
evaluation and management service provided on August 3, 2021, to September 28, 2021, by an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the LifeVest you received on October 2, 
2019. 
 
You asked the Plan to waive the coinsurance for the LifeVest. You say that it is unfair that you have to pay this 
amount.  You said you had the vest less than two and a half weeks and it was too heavy.  You returned the 
item, but are still getting billed. The Plan denied your request. The Plan says you were charged this coinsurance 
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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay 20% coinsurance for the LifeVest. The LifeVest falls within the durable medical 
equipment benefit category. This coinsurance applies for the month you had the item, regardless of whether or 
not the item was useful for you. 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 the LifeVest you received 
on October 2, 2019.