Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on July 01, 2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you already hit your maximum out 
of pocket max, and should not owe this. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $25 copayment 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 copayment for an office visit provided on July 01, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical spine 
without contrast (72141). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary for 
the enrollee. The Plan denied your request. The Plan says this service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that there is no documentation in 
the medical records provided that indicates the MRI at issue in this case meets all Medicare criteria to be 
considered medically reasonable and necessary for the enrollee. The provided records do not document six 
weeks of provider directed conservative treatment with no improvement in symptoms. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI) of the cervical spine without contrast (72141).
Appeal type: Drugs
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 a CGM. You say that you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says you do not meet Medicare criteria for the requested CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ViviGen allograft procedure. 
 
You asked the Plan to pre-approve ViviGen allograft. You say that you are appealing with records. The Plan 
denied your request. The Plan says studies have not proven that the use of this product during spinal surgery is 
better than standard allograft products. 
 
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 ViviGen allograft. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found ViviGen allograft is experimental for use in spinal surgery. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ViviGen allograft have not been met. Therefore, we decided that the Plan does 
not have to pre-approve ViviGen allograft procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on November 29, 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 procedure code 52001 is not supported. 
 
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 52001 is cystourethroscopy with irrigation and 
evacuation of multiple obstructing clots. 
 
We find that CPT code 52001 is not supported in the medical record. Specifically, there is no documentation of 
cystourethroscopy with irrigation and evacuation of multiple obstructing clots. 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 pay for the surgical services rendered on November 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple 
power options (K0861), Center Mount Power Elevating Leg rests (E1012), expandable controller (E2377), 
harness (E2313), electronic connection (E2311), battery (E2363), joystick mount (K0108), back cushion 
(E2620), armrest (E0973), ankle strap (E0951), headrest (E0955), skin protectant seat cushion (E2607), tilt 
only power seating system (E1002), power leg elevation system (E1010). 
 
You asked the Plan to pre-approve a Group 3 PWC with multiple power options and related accessories. You 
say that the items are medically necessary. The Plan denied your request. The Plan says the member does not 
have medical need for multiple power options included with K0861 group 3 power wheelchair; only ONE 
power option is requested. As the Group 3 Power Wheelchair with multiple power options is not reasonable 
and necessary, none of the requested accessories can be covered. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair with multiple power 
options is covered when the criteria listed in the Medicare Rules section is 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 Group 3 PWC with multiple power 
options and related accessories. Our reviewer says that these items are not medically necessary. Our physician 
reviewer found the clinical documentation is insufficient to support that the enrollee is at high risk for 
development of a pressure ulcer, and is unable to perform a functional weight shift, OR that the enrollee 
utilizes intermittent catheterization for bladder management and is unable to independently transfer from the 
wheelchair to the bed, OR that the power seating system is needed to manage increased tone or spasticity. The 
submitted documentation also does not support that it is medically necessary to control power options through 
a separate joystick or that the enrollee has a condition, cast or brace preventing 90-degree flexion at the knee, 
or lower limb edema. 
 
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 Group 3 PWC with multiple power options and related accessories have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair 
(PWC) with multiple power options (K0861), Center Mount Power Elevating Leg rests (E1012), expandable 
controller (E2377), harness (E2313), electronic connection (E2311), battery (E2363), joystick mount (K0108), 
back cushion (E2620), armrest (E0973), ankle strap (E0951), headrest (E0955), skin protectant seat cushion 
(E2607), tilt only power seating system (E1002), power leg elevation system (E1010).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a full length flip-back armrest and width extension kit 
for a power wheelchair (PWC). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are included in the approved PWC. 
 The Plan must follow Medicare rules. Medicare rules say that procedure code code E1012 includes all 
components of the leg rest and a power tilt seating system (E1002) includes a width extension kit. 
 
We looked at the file and Medicare rules. The file shows that the requested full length flip-back armrest and 
width extension kit are already included in the approved power wheelchair. Therefore, we decided that the Plan 
does not have to pre-approve a full length flip-back armrest and width extension kit for a power wheelchair 
(PWC).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a multi-level lumbar fusion surgery.

You asked the Plan to pre-approve a multi-level lumbar fusion surgery. You say that the services are medically
necessary. The Plan denied your request. The Plan says the services are 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 multi-level lumbar fusion surgery.
Our reviewer says that the requested services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the patient is a smoker and there is no history of smoking cessation for at
least 12 weeks. Smoking is a contraindication to spine fusion surgery.

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 multi-level lumbar fusion surgery have not been met. Therefore, we decided
that the Plan does not have to pre-approve a multi-level lumbar fusion surgery.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 76642 billed for date of service October 4,
2022.

You asked the Plan to pay for procedure code 76642. You say that this service was medically necessary. The
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value cannot be paid when the MAI value is 2.

In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of
procedure code 76642 have not been met. Therefore, we decided that the Plan does not have to pay for
procedure code 76642 billed for date of service October 4, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs a mobile primary care service 
because they are home bound and recently discharged from the hospital. The Plan denied your request. The 
Plan says medically necessary care is available in-network. 
 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (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 skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on January 19, 2022.

You asked the Plan to pay for the lab services. You say that the claim should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim.

The Plan must follow Medicare rules. Medicare rules say that, for 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 provided on January 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341 and 88342 billed for date of service 
March 30, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the rules for payment have not been met. 
 
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 88342 is a column II code to column I code 88344. The code at issue 
has not been billed with an appropriate modifier to bypass the edit. Because code 88342 is not eligible for 
payment, add-on code 88341 is also not covered. Based on the claim submitted, the Medicare billing criteria 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 88341 and 
88342 billed for date of service March 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the spinal injection provided on July 8, 
2022, and the office visit provided on July 28, 2022. 
 
You asked the Plan to waive the copayment for the spinal injection and office visit. You say that you cannot 
afford these high copayments and have never had to pay this much before. 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 $200 
copayment per stay for each Medicare-covered surgery performed in an ambulatory surgical center. Your 
contract with the Plan also clearly says that you must pay a $25 copayment for each specialist physician visit. 
 
You have been asked to pay a $200 copayment for a spinal injection. A spinal injection falls within the 
Medicare-covered surgery performed in an ambulatory surgical center benefit category. You have also been 
asked to pay a $25 copayment for an office visit, which falls within the specialist physician visit 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 spinal injection provided on July 8, 2022, 
and the office visit provided on July 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment and the coinsurance for the oral evaluation
(D0120) and the periodontal scaling and root planing (D4341) provided on August 18, 2022, September 6,
2022, and September 20, 2022.

You asked the Plan to waive the copayment and the coinsurance for the dental services. You say that you are
upset with the amount that was charged. 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 $25
copayment for a periodic oral evaluation and a 20% discount off the specialist's customary fee when services
are performed by a plan specialist. The total allowed amount for each periodontal scaling and root planing was
$357 with a coinsurance amount of $285.60 ($357 total amount x 80% coinsurance). There was a total of 4
periodontal scaling and root planing completed; therefore, the total coinsurance amount was $1,142.40
($285.60 coinsurance amount x 4 times).

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

You have been asked to pay a $25 copayment for the oral evaluation and a $1,142.40 for the periodontal
scaling and root planing. This item/service falls within the dental 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 and the coinsurance for the oral evaluation (D0120) and the periodontal
scaling and root planing (D4341) provided on August 18, 2022, September 6, 2022, and September 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99221) provided on August 17, 2022.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in
the global surgery payment.

The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global
surgery procedures includes payment for services related to the surgery when furnished by the physician who
performs the surgery.

We looked at the file and Medicare rules. Payment for the requested services (99221) is included in the global
surgery payment for the procedure (10140) provided on the same date of service. 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 services (99221) provided on August 17, 2022.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve five additional home health skilled nursing visits.
You asked the Plan to pre-approve home health services. The Plan denied your request. The Plan says the
services are not medically necessary.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.

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 home health services. Our reviewer
says that the services are not medically reasonable and necessary. Our physician reviewer found that the
enrollee has been medically stable without any recent exacerbations of chronic medical problems or
hospitalizations. The documentation does not support that the enrollee requires additional skilled nursing
services to provide treatment that is 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 home health services have not been met. Therefore, we decided that the Plan
does not have to pre-approve five additional home health skilled nursing visits.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services provided on April 18, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that an 
inappropriate place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. 
 
We find that the claim at issue was billed with place of service code 13, indicating the specimen was obtained 
at an assisted living facility. Based on this information, we decided that Medicare rules for coverage have been 
met. Therefore, we decided that the Plan has to pay for the lab services provided on April 18, 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from June 1, 2022, to 
August 3, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says this provider is not a 
Medicare qualified mental health care professional. 
 
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist is not eligible to 
participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Marriage Family Therapist. 
Medicare says that a Marriage Family Therapist is not eligible to participate in the Medicare program. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided from June 1, 2022, to 
August 3, 2022.