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

 
We decided that the Plan does not have to pre-approve a pneumatic compressor device. 
 
You asked the Plan to pre-approve a pneumatic compressor device. 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 follows Medicare rules. Medicare rules say that pneumatic compression devices are covered when 
specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a pneumatic compressor device. Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case, the 
documentation indicates that the use of a sequential pump has been attempted and been ineffective. 
Additionally, the documentation does not support that you have physical findings consisting of truncal, 
abdominal or chest edema. The requested pneumatic compressor device is not 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 a pneumatic compressor device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a pneumatic compressor device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulatory continuous glucose monitoring 
provided on November 3, 2021. 
 
You asked the Plan to waive the copayment for glucose monitoring. You say that you were not told there 
would be a patient copayment charge for facility components. You also say that the doctor informed you the 
procedure would be covered by your insurance, otherwise you would not have had it done. 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 $110 copayment for each outpatient hospital service. The contract also says that if you see a provider that is part of a 
hospital-based or provider-based practice, you will pay your outpatient hospital clinic or facility cost-share plus 
the primary or specialty care provider cost-share if an office visit occurs at the time of the service the office 
visit is considered to be separately payable by the Plan. 
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$110 copayment for glucose monitoring. Glucose monitoring falls within the Outpatient Hospital 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 ambulatory continuous glucose 
monitoring provided on November 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 29 extractions and the related anesthesia. 
 
You asked the Plan to pre-approve 29 extractions and the related anesthesia. You say that the services are 
necessary. The Plan denied your request. The Plan says the 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. The Plan covers 2 extractions 
per calendar year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of 29 extractions and the related anesthesia have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 29 extractions and the related anesthesia.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Laboratory services provided on September 21, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Laboratory services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says prior authorization is required for an out-of-network 
visit. 
 
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 Laboratory services provided on September 21, 
2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network 
(OON) provider on February 15, 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 laboratory services rendered by the out-of-network (OON) provider on 
February 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services rendered on September 17, 
2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 3 represents TC only codes. 
 
 
 
 We looked at the file and Medicare rules. Billed procedure code 99153 (moderate sedation services) has a 
PC/TC indicator of 3 and no separate PC payment. Therefore, we decided that the Plan does not have to pay for 
the moderate sedation services rendered on September 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the services are 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 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 Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is considered experimental for lower back pain. More 
research is needed to show safety and efficacy. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 24, 2021. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says you must 
receive your care from a network provider. In most cases, care you receive from an out-of-network provider 
will not be covered. Here are three exceptions: The plan covers emergency care or urgently needed services 
that you get from an out-of-network provider. If you need medical care that Medicare requires our Plan to 
cover and the providers in our network cannot provide this care, you can get this care from an out-of-network 
provider. Prior Authorization should be obtained from the Plan prior to seeking care. The Plan covers kidney 
dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the 
Plans service area. 
 
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 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 physician's services provided on February 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for  inpatient hospital care provided from 
October 31, 2021, to November 5, 2021, and from December 8, 2021, to December 17, 2021. 
 
You asked the Plan to waive the copayments for  inpatient hospital care. You say that the $1,950 charge is not 
appropriate because there was less than 60 days from your release from the previous hospital stay. The Plan 
denied your request. The Plan says the copayments applied 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 $325 
in-network copayment per day, days 1 to 6 for inpatient hospital care.  You have been asked to pay a total copayment of $3,575 for inpatient hospital care ($325/day x 11 days = 
$3,575). The inpatient hospital care falls within the Inpatient hospital 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 copayments for  inpatient hospital care provided from October 31, 2021, to 
November 5, 2021, and from December 8, 2021, to December 17, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging services. 
 
You asked the Plan to pre-approve myocardial perfusion imaging services. You say that this procedure is 
medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage of 
this service have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that cardiovascular nuclear imaging is subject to the 
criteria listed in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve myocardial perfusion imaging services. 
Our reviewer says that the requested services are not medically reasonable and necessary. Our physician 
reviewer found at issue is the medical appropriateness and necessity of carrying out a radionuclide stress test. 
The patient has undergone stress echocardiography, with no evidence of ischemia. Ambulatory 
electrocardiogram also was negative. There is no evidence provided that would support the need for 
radionuclide stress testing. In summary, there is insufficient documentation to support the medical necessity for 
the requested cardiac stress testing in this patients clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of myocardial perfusion imaging services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve myocardial perfusion imaging services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 20 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81201, 81408, 81406, 81317, 81405, 81404, 
81407) provided February 24, 2020. 
 
You asked the Plan to pay for the lab services. You say that the 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 81201, 81408, 81406, 81317, 81405, 81404, and 81407 are not supported in the 
medical record. Specifically, the codes billed are included in 81432 which was approved. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (81201, 81408, 81406, 81317, 81405, 81404, 81407) 
provided February 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids provided on August 23, 2021. 
 
You asked the Plan to pay for hearing aids. You say that the enrollee was not told he needed to go through the 
Plans hearing provider. The Plan denied your request. The Plan says hearing aids ordered through providers 
other the Plan's hearing provider are not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when ordered through the Plans hearing provider. 
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not ordered through the 
Plans hearing provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids 
have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on 
August 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital outpatient clinic visit (G0463) provided on 
December 20, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for hospital outpatient clinic visit. You say that the patient was referred to this 
provider by the primary care provider (PCP) for liver disease. The Plan denied your request. The Plan says this 
provider is not a network provider with the Plan, and they have also determined that these services are not 
urgent or emergent, nor were they approved in advance. The Plan also says that these services were denied 
because of referral not authorized by the primary care provider (PCP). 
 
 
 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 hospital outpatient clinic visit (G0463) provided 
on December 20, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Computed tomography (CT) scan (70450) provided on 
November 29, 2021. 
 
You asked the Plan to pay for code 70450. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered 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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the Computed tomography (CT) scan (70450) provided on 
November 29, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring, from 
outside the operating room (remote or nearby), (G0453) provided on November 23, 2021. 
 
You asked the Plan to pay for continuous intraoperative neurophysiology monitoring. You say that the 
continuous intraoperative neurophysiology monitoring was medically necessary. The Plan denied your request. 
The Plan says the continuous intraoperative neurophysiology monitoring was not medically necessary. 
 
The Plan follows Medicare rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for continuous intraoperative neurophysiology 
monitoring. Our reviewer says that continuous intraoperative neurophysiology monitoring, from outside the 
operating room (remote or nearby) is not medically necessary. Our physician reviewer found that the 
monitoring report states that the type of surgery performed was a parathyroid exploration. There was no 
operative report provided for review. In as much it cannot be determined that surgery was performed for an 
indication for which the LCD supports provision of this service: "high-risk total removal of a complete lobe of 
the thyroid, removal of the entire gland, or involves re-entry (re-operation) to a prior surgical field where scar 
tissue obscures the visual path of the recurrent laryngeal nerve". In as much this type of procedure would not 
have otherwise been eligible for coverage of IONM services per the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuous intraoperative neurophysiology monitoring have not been met. 
Therefore, we decided that the Plan does not have to pay for continuous intraoperative neurophysiology 
monitoring, from outside the operating room (remote or nearby) (G0453) provided on November 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87150, 87486, 87496, 87498, 87502, 87503, 
87532, 87541, 87581, 87634, 87801) provided April 29, 2020. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the records do not support the billed services. 
 
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 the lab services 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 lab services (87150, 87486, 87496, 87498, 87502, 87503, 87532, 87541, 
87581, 87634, 87801) provided April 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthotics (L1851, L2397) provided November 1, 2021. 
 
You asked the Plan to pay for the orthotics. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed items. 
 
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 medical records which support medical necessity for the supplies provided in this 
case. The records do not show that the enrollee was seen by the ordering physician. 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 orthotics (L1851, L2397) provided November 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Debridement of nail(s) (11721) provided on February 4, 
2021. 
 
You asked the Plan to pay for code 11721. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered 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, we have confirmed that code 11721 
is a column II code to column I code 11056. 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 Debridement of nail(s) (11721) provided on February 4, 
2021.