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

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiography procedure (93306). 
 
You asked the Plan to pre-approve transthoracic echocardiography. You say that the requested service is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 
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 transthoracic echocardiography. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that at issue is the medical necessity of transthoracic echocardiography in the absence 
of any change in cardiac symptoms, signs or physical findings according to the submitted records. Clinical 
guidelines do not support carrying out a repeat transthoracic echocardiography procedure in this clinical 
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 transthoracic echocardiography have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a transthoracic echocardiography procedure (93306).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the out-of-network mental health telehealth 
services provided on August 09, 2022. 
 
You asked the Plan to waive the copayment for the out-of-network mental health telehealth services. You say 
that you were informed that this provider was actually in-network. The Plan denied your request. The Plan says 
this cost sharing was charged 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 $58.25 
copayment for out-of-network mental health services. 
 
You have been asked to pay a $58.25 copayment for the out-of-network mental health telehealth services. This 
item/service falls within the out-of-network mental health 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.The allowed amount for the out-of-network 
telehealth services is $58.25. Since this amount is less than the $65 copayment per the EOC, you are only responsible for the lesser amount. Therefore, we decided that the Plan does not have to waive the copayment 
for the out-of-network mental health telehealth services provided on August 09, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy visits provided on June 
23, 2022, to July 22, 2022. 
 
You asked the Plan to waive the copayment for physical therapy visits. You say that you didnt request these 
services so you shouldnt have to pay for them. The Plan denied your request. The Plan says this cost sharing 
was charged 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 $20 
copayment for Outpatient rehabilitation services. 
 
You have been asked to pay a $20 copayment for physical therapy visits. This item/service falls 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.You have been asked to pay $120 ($20 x 6 visits) copayment for the physical 
therapy visits. Therefore, we decided that the Plan does not have to waive the copayment for physical therapy 
visits provided on June 23, 2022, to July 22, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visit provided on August 11, 2022. 
 
You asked the Plan to waive the copayment for ER visit. You say that you felt fine but were told to go to the 
ER anyways so you shouldnt have to pay for this. The Plan denied your request. The Plan says this cost sharing 
was charged 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 $90 
copayment for Emergency care. 
 
You have been asked to pay a $90 copayment for ER visit. This item/service falls within the Emergency care 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for ER visit provided on August 11, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a primary care visit provided on April 08, 
2022. 
 
You asked the Plan to waive the copayment for a primary care visit. You say that you feel the services should 
be covered because the claims are causing you financial hardship. The Plan denied your request. The Plan says 
this cost sharing was charged 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 $10 
copayment for physician/practitioner service. 
 
You have been asked to pay a $10 copayment for a primary care visit. This item/service falls within the 
physician/practitioner service 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 primary 
care visit provided on April 08, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic monitoring services (95940, 95861, 95938) 
provided on April 19, 2022. 
 
You asked the Plan to pay for the diagnostic monitoring services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the codes billed are not separately payable. 
 
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 codes 95940, 95861, & 95938 are not supported in the medical record. Specifically, when an 
enrollee is an inpatient payment for technical components are included in the payment to the facility. Based on 
this information, we decided that Medicare rules for coverage of the diagnostic monitoring services have not 
been met. Therefore, we decided that the Plan does not have to pay for diagnostic monitoring services (95940, 
95861, 95938) provided on April 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that this device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the criteria are not 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 treat with 
insulin three or more times per month or use an insulin pump. 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 pre-approve a Dexcom G6 continuous glucose monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) of the head or brain 
(70450). 
 
You asked the Plan to pre-approve a CT scan of the head or brain. The Plan denied your request. The Plan says 
the enrollee does not meet criteria for the requested CT of the brain. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT scan of the head or brain. Our 
reviewer says that a CT scan of the head or brain is not reasonable and necessary. Our physician reviewer 
found on several clinic visits the enrollee has had a normal neurological exam. Our reviewer found on October 
13, 2022, a CT of the brain without contrast was ordered but the reason for such a request is not detailed in the 
submitted records. Our physician reviewer also found that without such details, the medical necessity of the 
requested CT of the brain without contrast is not established in the records submitted. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan of the head or brain have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a computed tomography (CT) of the head or brain (70450).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 75726 and 75774 billed for date of service 
June 15, 2022. 
 
You asked the Plan to pay for procedure codes 75726 and 75774. The Plan denied your request. The Plan says 
payment for codes 75726 and 75774 is bundled into payment for code 37242. 
 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 codes 
75726 and 75774 are column II codes to column I code 37242. 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 codes 75726 
and 75774 billed for date of service June 15, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 86003 billed for date of service February 3, 2022. 
 
You asked the Plan to pay for procedure code 86003. You say that this service was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says that the Local Coverage Determination 
criteria for this service are not met, as frequency limitations were exceeded. 
 
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 Plan does not provide a clear argument to explain why this 
service was denied. The other service on the same claim has been paid and the Plan does not clearly explain 
what criteria are not met for this service but were met for the other service. Records were provided to support 
this service and the Local Coverage Determination does not mention any criteria which have clearly not been 
met. Therefore, we decided that the Plan has to pay for procedure code 86003 billed for date of service 
February 3, 2022.  
 
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 pay for a physician visit provided on August 23, 2022. 
 
You asked the Plan to pay for a physician visit. You say that you disagree with the denial to reimburse the cost 
of the office visit with an out-of-network provider. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a physician visit 
provided on August 23, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for an emergency department visit (code 99285) provided on  
January 15, 2022. 
 
You asked the Plan to pay for an emergency department visit (code 99285). You say that the services are coded 
applying industry recognized emergency medical coding standards. The Plan denied your request. The Plan 
says that the code was adjusted based on CMS policy. 
 
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 Plan has not provided us with a coding rule that was used to 
make this decision. Therefore, we decided that the Plan has to pay for an emergency department visit 
(code 99285) provided on January 15, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the FreeStyle Libre 14-day sensor. 
 
You asked the Plan to pre-approve the FreeStyle Libre 14-day sensor. You say that the medical records 
provided support the necessity of the requested services. The Plan denied your request. The Plan says the 
enrollee is not insulin treated and does not meet the prior approval criteria. 
 
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 perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the FreeStyle Libre 14-day sensor have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the FreeStyle Libre 14-day sensor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left shoulder surgery. 
 
You asked the Plan to pre-approve left shoulder surgery. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 left shoulder surgery. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation is not evident regarding a trial and failure of recent, 
reasonable, and comprehensive less invasive conservative care measures. It is not clearly documented as to 
when he underwent the original total shoulder replacement and the failed conservative measures since. 
Moreover, there are no updated imaging studies to potentially detail a total shoulder failure that would require a 
revision procedure, and/or evidence of infection. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
left shoulder surgery, in this case, 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 left shoulder surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve left shoulder surgery.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99308) provided on May 23, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says Original Medicare is liable for payment for this service. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for physician services (99308) provided on May 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve, 
including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628) and thermal destruction of 
intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or 
sacral (64629). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that you disagree with a wrongful denial for 
intraosseous ablation of the basivertebral nerve, which is accomplished with the lntracept Procedure. This 
procedure improves the quality of life of patients suffering from vertebrogenic low back pain. The lntracept 
Procedure, not just the device received initial FDA clearance the summer of 2016. That clearance means the 
procedure is safe and effective. The Plan denied your request. The Plan says unproven and not medically 
necessary procedures are not covered by Medicare due to insufficient evidence of efficacy. Intracept device 
does not meet accepted standards of medical practice. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure is experimental. More research is needed to show safety and 
evidence of efficacy of this procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve, including all imaging 
guidance; first 2 vertebral bodies, lumbar or sacral (64628) and thermal destruction of intraosseous 
basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral (64629).