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

 
We decided that the Plan does not have to pay for the thoracoscopy services coded 32666 provided on June 30, 
2022. 
 
You asked the Plan to pay for the thoracoscopy services as billed. You say that you would like this claim 
reprocessed based on the medical documentation. The Plan denied your request. The Plan says the 
documentation does not support payment for the services as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 32666 is thoracoscopy, surgical; with therapeutic wedge 
resection (eg, mass, nodule), initial unilateral. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the thoracoscopy services as billed. Our reviewer says that 
the documentation does not support the services as billed. Our reviewer found the record states that the 
procedure was discontinued due to medical contraindication and was not performed. It would be correct to 
report 32666 with modifier 53 as the appellant stated. However, the claims in the case file does not show that 
32666 was reported with a modifier as required. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the thoracoscopy services as billed have not been met. Therefore, we decided 
that the Plan does not have to pay for the thoracoscopy services coded 32666 provided on June 30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Udenyca. 
 
You asked the Plan to pre-approve Udenyca. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Udenyca. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of acute lymphoblastic leukemia on Truxima and Cytarabine. The 
documentation does not support that the enrollee has tried and failed Zarxio. The documentation does not 
support that Zarxio would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, 
the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Udenyca have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Udenyca.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardio-thoracic surgery evaluation to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve surgical evaluation. You say that an in-network physician would not have 
privileges with your program. The Plan denied your request. The Plan says this provider is out-of-network with 
the Plan and the enrollee can be evaluated by an in-network surgeon. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a cardio-thoracic surgery evaluation to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 76641 billed for date of service October 3, 2022. 
 
You asked the Plan to pay for the billed services. You say that the records support the procedure. The Plan 
denied your request. The Plan says that the code has an MUE value of 1. 
 
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 76641 is ultrasound, breast, unilateral, real time with 
image documentation, including axilla when performed; complete. We find that CPT code 76641 has an MUE 
value of 2. The claim shows that 2 units of service were billed. 1 unit of service was billed with modifier RT on 
a claim line, and 1 unit of service was billed with modifier LT on the other claim line. Based on this 
information, we decided that Medicare rules for coverage have been met. Therefore, we decided that the Plan 
has to pay for procedure code 76641 billed for date of service October 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a pacemaker check provided on September 
1, 2022. 
 
You asked the Plan to waive the copayment for a pacemaker check. You say that you disagree with the 
copayment. 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 $45 
copayment for Prosthetic devices and related supplies/for pacemaker checks.  
 
You have been asked to pay a $45 copayment for a pacemaker check. This item/service falls within the 
Prosthetic devices and related supplies/for pacemaker checks 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 pacemaker check provided on September 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the echocardiography and related services (C8924, 93325, 
Q9957) provided on June 9, 2022. 
 
You asked the Plan to pay for the echocardiography and related services. You say that you would like this 
claim reprocessed based on the medical records. The Plan denied your request. The Plan says this claim has not 
been billed as required by Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. In this case, this service was not reported with the required secondary 
diagnosis of mitral valve prolapse. Based on this information, we decided that Medicare rules for coverage of the echocardiography and related services have not been met. Therefore, we decided that the Plan does not 
have to pay for the echocardiography and related services (C8924, 93325, Q9957) provided on June 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair accessory, push-rim activated 
power assist system (E0986). 
 
You asked the Plan to pre-approve a manual wheelchair accessory. You say that you already had a physiatry 
evaluation and the therapist recommended the device in April 2022. The Plan denied your request. The Plan 
says you do not meet criteria for approval of the requested accessory. 
 
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 manual wheelchair accessory. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation indicates you require a manual wheelchair replacement 
as yours is worn beyond repair. The documentation by the physician and in the home evaluation by the physical 
therapist indicates that you require an ultra-light manual wheelchair with a push-rim activated power assist 
system due to upper extremity pain and weakness. 
 
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 manual wheelchair accessory have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a manual wheelchair accessory, push-rim activated power assist system 
(E0986).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140), and 
resin-based composite - three surfaces, anterior (D2332) provided on October 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to be reimbursed your $338.50. 
The Plan denied your request. The Plan says the denial is correct because these services are not covered by the 
Plans dental benefits or they are covered but the coverage benefit has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the limited oral evaluation - problem focused (D0140) was exhausted on date of service 
June 28, 2022.  
 Therefore, we decided that the Plan does not have to pay for a limited oral evaluation - problem focused 
(D0140), and resin-based composite - three surfaces, anterior (D2332) provided on October 31, 2022. The 
Plans dental benefits do not include coverage for the resin-based composite - three surfaces, anterior (D2332).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation - established patient (D0120), and 
prophylaxis - adult (D1110) provided on September 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are unable to clean your own teeth due to a 
brain tumor and have limited mobility. You also say that you have your teeth cleaned every four months to 
keep them in good health. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 23, 2022. Therefore, 
we decided that the Plan does not have to pay for a periodic oral evaluation - established patient (D0120), and 
prophylaxis - adult (D1110) provided on September 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction, erupted tooth or exposed root, tooth #19 
(elevation and/or forceps removal) (D7140) provided on April 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that this procedure was approved by the dentist 
office. You also say it was approved a second and third time. The Plan denied your request. The Plan says your 
benefit for the requested item or service $1,000 dollar limit was met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 13, 2022. 
Therefore, we decided that the Plan does not have to pay for an extraction, erupted tooth or exposed root, tooth 
#19 (elevation and/or forceps removal) (D7140) provided on April 26, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy visits provided on August 02, 2022, to August 
15, 2022. 
 
You asked the Plan to pay for psychotherapy visits. You say that you are appealing the claim payment denial. 
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 psychotherapy visits 
provided on August 02, 2022, to August 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuromonitoring services (95908, 95865, 95886, 95937) 
provided July 8, 2022. 
 
You asked the Plan to pay for the neuromonitoring services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 95908, 95865, 95886, and 95937 are not supported in the medical record. Specifically, 
the record does not specify where electrode needles were placed in specific nerves to perform stimulation and 
recording. It cannot be verified that 3-4 separate studies were performed. The record states that the 
endotracheal tube was used to monitor the laryngeal nerve. This does not support that a needle EMG was 
performed on the larynx; no needle insertion into the muscle is documented. Train of four testing is bundled 
with intraoperative neuromonitoring and should not be reported separately. Based on this information, we 
decided that Medicare rules for coverage of the neuromonitoring services have not been met. Therefore, we decided that the Plan does not have to pay for neuromonitoring services (95908, 95865, 95886, 95937) 
provided July 8, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat polysomnography (95811). 
 
You asked the Plan to pre-approve a repeat polysomnography. The Plan denied your request. The Plan says this 
request does not meet the Medicare or health plan coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a follow-up polysomnography or a cardio-respiratory 
sleep study is indicated for the conditions listed in the Medicare rules section of this letter. 
 
 
  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 repeat polysomnography. Our 
reviewer says that a repeat sleep study with positive airway pressure (PAP) titration is not medically necessary. 
Our physician reviewer found this enrollee was diagnosed with obstructive sleep apnea (OSA) on a home sleep 
study on September 1, 2021, and was started on CPAP 7 following PAP titration. Our reviewer found that the 
enrollee reports no sleep symptoms currently, but PAP use does not meet minimum Medicare use criteria of at 
least 70% of days with at least 4 hours per day. Our physician reviewer also found that since the enrollee has a 
diagnosis of OSA and the current CPAP settings are effective, there is no medical need for a repeat study. 
 
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 repeat polysomnography have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a repeat polysomnography (95811).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a patient lift, hydraulic or mechanical, includes any seat, 
sling, strap(s) or pad(s) (E0630) provided on June 27, 2022. 
 
You asked the Plan to pay for a patient lift. You say that new documents were submitted and consist of a 
delivery ticket for various dates other than the billed date of service. The Plan denied your request. The Plan 
says the documentation submitted did not include a valid physician order; therefore, the billed service cannot 
be verified. It is noted that multiple attempts were made to contact the provider for additional information. 
 The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order and the billed service cannot be verified for the supplies 
provided in this case. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for a patient lift, 
hydraulic or mechanical, includes any seat, sling, strap(s) or pad(s) (E0630) provided on June 27, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Monovisc injection provided on August 26, 2022. 
 
You asked the Plan to pay for the injection. You say that Monovisc for osteoarthritis of left knee was medically 
necessary. The Plan denied your request. The Plan says the enrollee did not meet the step therapy requirements. 
  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 injection. Our physician reviewer found 
that the Plan requires a trial of drugs Synvisc/Synvisc One or Euflexxa before they will approve Monovisc. Our 
physician reviewer found that based on the medical records provided there is no indication that the enrollee has 
tried and failed the required drugs. Our physician reviewer found that there is no indication that the Plans 
required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injection have not been met. Therefore, we decided that the Plan does not have 
to pay for the Monovisc injection provided on August 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit provided on January 04, 
2022. 
 
You asked the Plan to waive the deductible for an office visit. You say that you are disputing the share cost. 
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 
$270.10 deductible for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $270.10 deductible for an office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 deductible for an office visit provided on January 04, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency ambulance transportation (A0429) and 
ground mileage (A0425) provided on August 31, 2022. 
 
You asked the Plan to pay for the emergency ambulance transportation and ground mileage. You say that the 
enrollee was transported to the emergency room from a behavioral health center due to a head injury resulting 
from a fall. You also say that this is a medically necessary transport for a higher level of care not included in 
the global payment. The Plan denied your request. The Plan says on this date of service the enrollee was in an 
inpatient hospital status. 
 
The Plan must follow Medicare rules. Medicare rules say that transportation, including transportation by 
ambulance, to and from another hospital or freestanding facility to receive specialized diagnostic or therapeutic 
services not available at the facility where the patient is an inpatient is covered under Part A. 
 
We looked at the file and Medicare rules. The record shows that the enrollee was in an inpatient hospital status 
from August 30, 2022, to September 7, 2022. This transportation occurred between these dates of service. 
Based on this information, we decided that Medicare rules for coverage of the emergency ambulance 
transportation and ground mileage have not been met. Therefore, we decided that the Plan does not have to pay 
for the emergency ambulance transportation (A0429) and ground mileage (A0425) provided on August 31, 
2022.