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

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 4, 
2021. 
 You asked the Plan to pay for procedure code 70450. You say that this patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for this code is bundled into payment for 
70496. 
 
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 procedure code 70450 billed for date of service November 4, 
2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for breast reduction services (procedure code 19318) provided to the 
enrollee on May 12, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that 19318 is not supported by the medical records submitted. 
 
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 19318 is "Breast reduction." 
 
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 services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found the record indicates that a Wise type 
incision was reopened and breast tissue and skin was excised to achieve a reduction in breast size. The 
elements of the code have been satisfied and substantiated in the medical records. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
breast reduction services (procedure code 19318) provided to the enrollee on May 12, 2021. 
  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving but is still somewhat unstable with intermittent 
hypotension and requires short-term additional acute care services at this time that can be safely administered 
at the current facility until more stable and appropriate for a lower level of care. There are no services at the 
LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to a 
lower level of care may be considered when treatment has completed and the enrollee is more 
hemodynamically stable. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a esophagogastroduodenoscopy (EGD) (43235). 
 
You asked the Plan to pre-approve an EGD. You say that the requested service is necessary. The Plan denied 
your request. The Plan says the requested service 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 an EGD. Our reviewer says that the 
requested EGD is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the provided documentation does not support that Barrett's esophagus surveillance recommendations are 
applicable to this case. The reviewer also found that the available records do not support the medical 
appropriateness nor necessity for repeated endoscopic surveillance as proposed. 
 
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 EGD have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a esophagogastroduodenoscopy (EGD) (43235).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and coinsurance for new patient outpatient visit 
on July 13, 2021. 
 
You asked the Plan to waive the deductible and coinsurance for outpatient visit. You say that that you were 
covered under Medicaid for July 2021. The Plan denied your request. The Plan says the amount you are being 
charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a 20% coinsurance and a $75 deductible which applies to new patient 
outpatient visit. At the time this claim was processed, $0 of the $75 deductible had been met. The allowed 
amount of the claim is $104.59, resulting in a deductible amount of $75. After the deductible is met the 
remaining allowed amount of the claim is $29.59, resulting in a coinsurance amount of $5.92 because of the 
20% coinsurance for a new patient outpatient visit. Therefore, your total cost-sharing amount is $80.92. 
 
 The item or service you asked the Plan to waive the deductible and coinsurance for falls within the 
Physician/Practitioner services, including doctor's office visits benefit category. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a 20% coinsurance and a $75 deductible which 
applies to new patient outpatient visit. This cost sharing is a contractual obligation that had not been met at the 
time outpatient visit was received on July 13, 2021. Therefore, we decided that the Plan does not have to waive 
the deductible and coinsurance for new patient outpatient visit on July 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam rendered on December 9, 
2021. 
 
You asked the Plan to waive the copayment for these services. You say that the services were routine and not 
medical. The Plan denied your request. The Plan says the copayment was 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 $50 
copayment for a medical eye exam.  
 
Review of the file shows that you had a medical eye exam on December 9, 2021. The exam was medical in 
nature and not routine because it was performed for the diagnosis of choroidal nevus. You have been asked to 
pay a $50 copayment for these services. These services fall within the medical eye exam benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the eye exam rendered on December 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Lateral retinacular release (27425-59) and the Biopsy 
(27324-59) provided on August 17, 2021. 
 
You asked the Plan to pay for codes 27425-59 and 27324-59. You say that the medical records support the use 
of modifier 59 with codes 27425 and 27324. The Plan denied your request. The Plan says the medical records 
do not support the use of modifier 59 with codes 27425 and 27324. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 codes 27425-59 and 27324-59 Our reviewer 
says that the medical records do not support the use of modifier 59 with codes 27425 and 27324. Our physician 
reviewer found based on the documentation provided, code 27425 does not meet criteria. Operative report does 
not describe this procedure was performed on a different compartment as the primary procedure, therefore a 
smaller procedure would be inclusive to the primary procedure and not reported separately. Code 27324 does not meet criteria.  Operative report does not describe a biopsy performed at a different anatomic location or 
patient encounter from the more extensive procedure.  In order to report this procedure, separate from the more 
extensive procedure, is if it precedes and leads to the more extensive 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 codes 27425-59 and 27324-59 have not been met. Therefore, we decided that 
the Plan does not have to pay for the Lateral retinacular release (27425-59) and the Biopsy (27324-59) 
provided on August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hyperthermia treatment (77600) provided on September 
24, 2021. 
 
You asked the Plan to pay for the hyperthermia treatment (77600). You say that CPT code 77600 was rebilled 
with XE modifier per the guidelines. You say that the medical records are proof that a separate procedure was 
performed, and the claim should be processed for payment. The Plan denied your request. The Plan says the 
provider has billed both 59 and XE on this claim but XE is the only appropriate modifier. 
  The Plan must follow Medicare rules. Medicare rules say that modifiers XE, XS, XP, XU were developed to 
provide greater reporting specificity in situations where modifier 59 was previously reported and may be used 
in lieu of modifier 59 whenever possible. 
 
In this case, the CPT Code Manual definition of code 77600 is hyperthermia, externally generated; superficial 
(ie, heating to a depth of 4 cm or less). 
 
We find that CPT code 77600 is not supported in the medical record. Specifically, only one modifier should 
have been billed. Based on this information, we decided that Medicare rules for coverage of the hyperthermia 
treatment (77600) have not been met. Therefore, we decided that the Plan does not have to pay for the 
hyperthermia treatment (77600) provided on September 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued acute inpatient hospitalization from March 
15, 2022, forward. 
 
You asked the Plan to pre-approve a continued acute inpatient hospitalization. You say that a lower level of 
care will not provide adequate care. The Plan denied your request. The Plan says the continued inpatient stay 
from March 15, 2022, forward 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 a continued acute inpatient 
hospitalization. Our reviewer says that the continued acute inpatient hospitalization is not considered medically 
reasonable and necessary in this case. Our physician reviewer found that the clinical documentation provided 
did not include documentation from March 15, 2022, forward to determine if the enrollee meets criteria for 
admission. Therefore, the review has determined that the continued inpatient hospitalization from March 15, 
2022, forward was 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 a continued acute inpatient hospitalization have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continued acute inpatient hospitalization from March 15, 
2022, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) provided 
November 5, 2021. 
 
You asked the Plan to pay for the chiropractic services. You say that you were not able to see your primary 
care physician. When she isn't available you see a chiropractor or an acupuncturist. That is why you went over 
your limit of 24 visits. The Plan denied your request. The Plan says the benefit has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The Plan covers up to 24 complementary/alternative 
health visits every calendar year.  
 
The records show that the 24th visit was met on October 22, 2021 Therefore, we decided that the Plan does not 
have to pay for the chiropractic manipulative treatment (98941) provided November 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc. 
 
You asked the Plan to pre-approve Orthovisc. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements have not been met. 
 
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 Orthovisc. Our reviewer says that the 
requirements for coverage of Orthovisc have not been met. Our physician reviewer found the Plan requires a 
trial of any two of Euflexxa, Supartz Fx, Durolane, or Gelsyn-3 before they will approve the requested drug. 
The records do not indicate you have tried any of these drugs or that these drugs would likely be less effective 
or have adverse effects. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orthovisc.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5mg Eliquis Tablets. 
 
You asked the Plan to pre-approve the Eliquis Tablets. You say that you would like reconsideration because the 
requested drug is medically necessary. The Plan denied your request. The Plan says this drug is not covered 
under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve 5mg Eliquis Tablets.  
 Benefits for the Eliquis Tablets may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 25, 2021, by an out-of-
network provider. 
 
You asked the Plan to pay for laboratory services. You say that the services at issue were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment for out-of-network services 
have not been met. 
 
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 May 25, 2021, by 
an out-of-network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Psychiatric diagnostic evaluation (90792) provided on 
February 23, 2021. 
 
You asked the Plan to pay for code 90792. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the enrollee had a psychiatric diagnostic evaluation on 
February 23, 2021. The submitted documentation supports 1 (one) unit of 90792, which was previously paid on 
another claim for this provider. There is no additional documentation supporting an additional service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 We find that 2 units of CPT code 90792 are not supported in the medical record. The medical record only 
supports 1 unit of CPT code 90792. Based on this information, we decided that Medicare rules for coverage of 
code 90792 on the second claim have not been met. Therefore, we decided that the Plan does not have to pay 
for the Psychiatric diagnostic evaluation (90792) provided on February 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lidocaine injection provided on April 20, 2021. 
 
You asked the Plan to pay for the injection services. The Plan denied your request. The Plan says an 
appropriate modifier was not billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
The file shows that CPT code J2001 was billed with code 20611. We find that CPT code J2001 may be eligible 
for payment when billed with this code pair. The claim does not show that the code at issue was billed with a 
modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for the lidocaine injection provided on 
April 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic dynamic response foot with multi-axial 
ankle (prosthetic code L5979). 
 
You asked the Plan to pre-approve prosthetic foot. You say that the enrollees current foot is not giving the 
range of motion for activities of daily living. The Plan denied your request. The Plan says the denial of 
authorization for this component is correct, because the enrollee already has a prosthetic foot that is less than 1 
year old and there is no documented physiologic change to warrant a new prosthetic foot. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and 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 prosthetic foot. Our reviewer says that 
the enrollee does not meet the Medicare criteria for the requested prosthetic foot. Our physician reviewer found 
there is no documentation that you meet criteria for the requested prosthetic foot in light of the prosthetic foot 
the enrollee already has. The records provided do not document that the enrollees current foot has been lost, 
stolen, irreparably damaged, or has exceeded its reasonable useful lifetime.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetic foot have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a prosthetic dynamic response foot with multi-axial ankle (prosthetic code L5979).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a botox injection to be provided at an out-of-network 
provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that you show improvement for the 
services administered by this provider. The Plan denied your request. The Plan says the service requested can 
be safely rendered in-network. 
 
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 botox injection to be provided at an out-of-network provider.