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

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676). 
 
You asked the Plan to pay for a pneumatic compression device. You say that you feel this is medically 
necessary because you are recovering from severe COVID last year. You were hospitalized and this device is 
the best method for your recovery moving forward. The Plan denied your request. The Plan says this service is 
not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for inpatient hospital care provided from 
September 8, 2022, to September 9, 2022. 
 
You asked the Plan to waive the coinsurance for the inpatient care. You say that the services were necessary, 
and you would like them covered as 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 50% 
coinsurance for inpatient hospital care (out-of-network).  
 
You have been asked to pay a total of $104.46, which is less than the 50% coinsurance for the inpatient care 
due to meeting your maximum out-of-pocket (MOOP) for the year. This item/service falls within the inpatient 
hospital care (out-of-network) 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 coinsurance for inpatient 
hospital care provided from September 8, 2022, to September 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network orthopedic surgeon. 
 
You asked the Plan to pre-approve these services. You say that the provider's office was formerly in-network 
and it would be in your best interest to have them perform your next surgery. The Plan denied your request. 
The Plan says the services are available from network providers. 
 
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 referral to an out-of-network orthopedic surgeon.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a nail removal procedure provided on 
October 17, 2022. 
 
You asked the Plan to waive the deductible for the nail removal. You say that you do not remember having this 
procedure done on that day. 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. Your 
contract with the Plan says that there is a $500 deductible which applies to certain items and services.  
 
The nail removal you asked the Plan to waive the deductible for falls within the outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to 
certain items and services. This cost sharing is a contractual obligation that had not been met at the time the 
nail removal was received on October 17, 2022. Therefore, we decided that the Plan does not have to waive the 
deductible for a nail removal procedure provided on October 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endometrial biopsy (58100-53) provided on October 14, 
2020. 
 
You asked the Plan to pay for the services. You say that you would like to appeal the denial. The Plan denied 
your request. The Plan says the service denied correctly. 
 
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 58100 is "Endometrial sampling (biopsy) with or without 
endocervical sampling (biopsy), without cervical dilation, any method (separate procedure)." 
 
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 not supported by the medical records. Our reviewer found that the medical record does not 
include documentation of a endometrial biopsy without cervical dilation, and therefore cannot be verified. In 
this case, an endometrial biopsy without cervical dilation procedure is not documented in the procedure report. 
 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 not been met. Therefore, we decided that the Plan does not 
have to pay for the endometrial biopsy (58100-53) provided on October 14, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the interpretation of the magnetic resonance imaging (MRI) of the hip 
provided on August 14, 2022. 
 
You asked the Plan to pay for the MRI interpretation. You say that this was billed with all necessary modifiers 
and should be paid. The Plan denied your request. The Plan says that an anatomical modifier is needed for this 
code. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan's denial rationale is that a modifier indicating which side the imaging 
was performed on must be used. However, review of the rules cited by the Plan to support this shows that it is 
in relation to Medically Unlikely Edits (MUEs). There is no MUE issue in this case, so the text of the rule cited 
by the Plan does not appear to apply to this situation. As such, we find this denial of payment to be 
unsubstantiated. Therefore, we decided that the Plan has to pay for the interpretation of the magnetic resonance 
imaging (MRI) of the hip provided on August 14, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Oncology (solid tumor as indicated by the label), somatic 
mutation analysis of BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) 
(0172U) provided June 30, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that without this test result, the physician may 
not be able to utilize the desired medical therapy, thus negatively impacting the enrollee's care. The Plan denied 
your request. The Plan says no medical records submitted with this appeal from the enrollees provider. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory services have been met. 
Medical records were needed to help determine the medical necessity for the procedure request. The records 
show that the Plan made several requests to obtain the medical records from the provider without success. 
Therefore, we decided that the Plan does not have to pay for the Oncology (solid tumor as indicated by the 
label), somatic mutation analysis of BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair 
associated) (0172U) provided June 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve these services. You say that you need the CGM to get your sugar issue 
under control. The Plan denied your request. The Plan says the criteria for coverage 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 you do not treat with insulin three 
or more times per day 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 continuous glucose monitor (CGM).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are requesting reconsideration of this denial. 
The Plan denied your request. The Plan says you have not met criteria to transfer to askilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (denosumab) injections. 
 
You asked the Plan to pre-approve the Prolia injections. You say that it is felt that this treatment is needed to 
improve the enrollee's bone density. The Plan denied your request. The Plan says the criteria for Prolia 
treatment have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 the Prolia injections. Our reviewer says 
that the requested treatment with Prolia is not shown to be medically reasonable and necessary. Our physician 
reviewer found based on the medical records provided and the Medicare-approved major drug compendia, 
there is no documentation that the Prolia at issue in this case meets all Medicare criteria for medically 
reasonable and necessary for the enrollee. The provided medical records do not document osteoporosis by bone 
density testing or osteopenia with high risk for fracture or evidence of a fragility fracture.  
 
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 Prolia injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Prolia (denosumab) injections.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99233) and hospital discharge 
day management services (99239) provided May 23, 2022, to May 26, 2022. 
 
You asked the Plan to pay for the hospital services. You say that please review the attached medical reports as 
requested and reprocess. The Plan denied your request. The Plan says the documents do not support level of 
care. 
 
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 99233 is subsequent hospital care evaluation and 
management code requires two out of these three key components: a detailed interval history, a detailed 
examination and medical decision making (MDM) of high complexity and 99239 is hospital discharge day 
management, more than 30 minutes. 
 
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 hospital services. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our reviewer found per CPT 
code description, 2 of 3 key components must be met or exceeded.  In this case, the records show history: 
expanded problem focused; Exam: comprehensive; MDM: straightforward.  CPT 99233 cannot be verified.  
There is a more appropriate code to report for the services provided May 23, 2022 to May 25, 2022. The 
medical record did not include hospital discharge day management. Was unable to cite, as this procedure was 
not found in documentation, and therefore cannot be verified. 
 
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 hospital services have not been met. Therefore, we decided that the Plan 
does not have to pay for the subsequent hospital care (99233) and hospital discharge day management services 
(99239) provided May 23, 2022, to May 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on July 18, 2022, 
billed with codes G0463, G1004, and 73200. 
 You asked the Plan to pay for the outpatient hospital services as billed. You say that this was billed correctly 
and should be paid. The Plan denied your request. The Plan says modifier -25 must be used with G0463 in this 
case. Without this modifier, the claim is returned to the provider and not paid. 
 
The Plan must follow Medicare rules. Medicare rules say that all outpatient hospital services are processed 
through the I/OCE which includes coding edits to prevent improper payments. OCE edit 21 returns the claim to 
the provider when an EM service is billed without modifier -25 on the same date of service as a status indicator 
S or T code. 
 
We looked at the file and Medicare rules. In this case, code G0463 is an EM code. Code 73200 has a status 
indicator of S. No modifier was appended to the EM code as required. Based on this information, we decided 
that Medicare rules for coverage of the outpatient hospital services as billed have not been met. Therefore, we 
decided that the Plan does not have to pay for the outpatient hospital services provided on July 18, 2022, billed 
with codes G0463, G1004, and 73200.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve injection(s), of diagnostic or therapeutic substance(s) (eg, 
anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle 
or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance 
(ie, fluoroscopy or CT) (CPT code 62323 x 2). 
 
You asked the Plan to pre-approve the injection. You say that the injections are medically necessary. The Plan 
denied your request. The Plan says that the injections are not 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 the injection. Our physician reviewer 
found the enrollee meets the LCD criteria and the request is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have been met. Therefore, we decided that the Plan has to pre-
approve injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, 
other solution), not including neurolytic substances, including needle or catheter placement, interlaminar 
epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT) (CPT code 
62323 x 2).  
 
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 physician's services provided on August 24, 2022. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says after 
multiple attempts to obtain proof of no medical coverage with member' s auto insurance, the appellant wasn't 
able to obtain proof to submit. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has not received 
proof medical coverage with enrollees auto insurance. As the secondary insurer, the Plan cannot be held 
responsible for the physician's services until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for physician's services provided on August 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve the office visits. You say that the services are medically necessary. The Plan 
denied your request. The Plan says 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 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 
office visits to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 43239 and 43249 provided to the enrollee 
on July 7, 2022. 
 
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 the records do not support the services 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 the denied codes is: 
 
CPT 43239: 
 
Esophagogastroduodenoscopy (EGD), flexible, transoral; with biopsy, single or multiple 
 
CPT 43249: 
 
Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter) 
 
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 not supported by the medical records. Our reviewer found that the medical record does not 
include documentation of flexible transoral EGD with biopsy or transcopic balloon dilation of esophagus. Of 
note, the medical record includes a colonoscopy procedure. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 43239 and 43249 provided to the enrollee on July 7, 2022.