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

 
We decided that the Plan does not have to pre-approve an x-ray of the foot. 
 
You asked the Plan to pre-approve the x-ray. You say that this is medically necessary. The Plan denied your 
request. The Plan says an x-ray cannot be approved without an order from a health care provider. 
 
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 x-ray. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the last clinic visit contains records detailing the care plan for the infected right foot; however, there is 
no mention nor order of a right foot x-ray. You state that you were in the emergency room, where you were 
told that you needed a follow-up x-ray to assess for increasing infection. However, there are no emergency 
room records included in the materials available for review. 
 
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 x-ray have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an x-ray of the foot.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient stay provided from March 3, 2021, to March 6, 2021. 
 
You asked the Plan to pay for the inpatient stay. You say that you were admitted into the hospital after being in 
the emergency room for over 10 hours on March 3, 2021. You also say that it appears the hospital had obtained 
the wrong authorization as well as coded the billing wrong. The Plan denied your request. The Plan says that 
the stay was appropriately downgraded from inpatient to observation. 
 
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 downgraded this hospital stay from inpatient to observation. You say 
that this is not the case because you were admitted to the hospital and stayed in the hospital for 3 days. The 
Plan did not submit medical records for this hospital stay, nor did the Plan submit documentation of attempts to 
obtain the medical records. Without medical records, the Plan has not shown that its decision to downgrade this 
stay from inpatient to observation is correct or medically justified. Therefore, we decided that the Plan has to 
pay for the inpatient stay provided from March 3, 2021, to March 6, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Iv tubing extension set coded S1015 provided on June 
25, 2021. 
 
You asked the Plan to pay for the Iv tubing extension set. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the items billed are not 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. 
 
In this case, the CPT Code Manual definition of code S1015 is Iv tubing extension set. 
 
We find that CPT code S1015 is not supported in the medical record. Specifically, this code has a status code 
of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code 
for reporting and payment of these services.  
 Based on this information, we decided that Medicare rules for coverage of the Iv tubing extension set have not 
been met. Therefore, we decided that the Plan does not have to pay for the Iv tubing extension set coded S1015 
provided on June 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) provided on July 
20, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient visit. You say that you have been staying in Colorado and went to 
an emergency room due to a possible heart attack. You were scheduled to come back for a follow up and do not 
understand why it was denied if it was part of the same emergency visit. The Plan denied your request. The 
Plan says enrollee?s must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 
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 the hospital outpatient clinic visit (G0463) 
provided on July 20, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist visit rendered on April 13,
2021.

You asked the Plan to waive the copayment for these services. You say that you shouldn't have to pay anything.
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 $25
copayment for specialist's office services.

Review of the file shows that you had a specialist office visit on April 13, 2021. You have been asked to pay a
$25 copayment for these services. These services fall within the specialist's office 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 the specialist visit rendered on April 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on April 21, 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 codes 73281 and 73283 are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
 The provider submitted a claim for procedure codes 43281 (surgical laparoscopy, repair of paraesophageal 
hernia), 43283 (surgical laparoscopy, esophageal lengthening procedure), and 43775 (surgical laparoscopy, 
gastric restrictive procedure). Codes 43281 and 43283 are column II codes with a modifier indicator of 1 when 
billed with column I code 43775. Codes 43281 and 43283 were not billed with an appropriate modifier to allow 
for separate payment. Therefore, we decided that the Plan does not have to pay for the surgical services 
rendered on April 21, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on June 22, 2021.

You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the charges. The
Plan denied your request. The Plan says the claims were processed correctly and you are being charged the
correct 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 $155
copayment for ultrasounds.

You have been asked to pay the allowed amount of $139.73, which is less than the $155 copayment for an
ultrasound. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies
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 ultrasound provided on June
22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiologic examination, spine, lumbosacral (72100)
provided on June 15, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the radiology service. You say that the x-ray of the lower back was the correct
course of action to take and would have been what you would have ordered. The Plan denied your request. The
Plan says enrollee's must receive their medical services from an in-network provider with the exception being
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization
before services being rendered.

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 the radiologic examination, spine, lumbosacral
(72100) provided on June 15, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network neurosurgeon. 
 
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 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 neurosurgeon.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight Psychotropic testing (81479) provided on June 
18, 2021. 
 
You asked the Plan to pay for GeneSight Psychotropic testing. You say that this is a Medicare-covered service. 
The Plan denied your request. The Plan says the requirements for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that in order for any pharmacogenomics services to 
be covered, the patient's medical record must clearly reflect that certain criteria have been met. The rules also 
say for Medicare to consider coverage and payment for any item or service, the information submitted by the 
supplier or provider must corroborate the documentation in the beneficiary's medical documentation and 
confirm that Medicare coverage criteria have been met. 
 
We looked at the file and Medicare rules. Although the order form indicates that the criteria for coverage have 
been met, medical records documenting this information have not been submitted. Based on this information, 
we decided that Medicare rules for coverage of GeneSight Psychotropic testing have not been met. Therefore, 
we decided that the Plan does not have to pay for GeneSight Psychotropic testing (81479) provided on June 18, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on June 23, 2021 and 
coded as 81479. 
 
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your 
request. The Plan says the testing billed is not covered by Medicare. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. The test at issue in this appeal was requested solely 
for screening purposes. There is no indication in the records provided that the results of this testing would 
determine a specific type of treatment. Medicare does not cover this test solely for screening purposes. 
Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on June 23, 
2021 and coded as 81479.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the maxillary partial denture, cast metal, resin base 
(D5213) and the mandibular partial denture, cast metal, resin base (D5214). 
 
You asked the Plan to pre-approve the dentures. You say that the services should be covered. The Plan denied 
your request. The Plan says you have exhausted the Plan's benefit for this service. 
 
  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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
maxillary partial denture, cast metal, resin base (D5213) and the mandibular partial denture, cast metal, resin 
base (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the right-sided radiofrequency ablation (RFA) of the sacral 
joint nerves and related outpatient hospital services provided on April 2, 2021. 
 
You asked the Plan to pay for the RFA procedure. You say that these services were medically necessary and 
should be reimbursed. The Plan denied your request. The Plan says this is not a proven procedure. 
 
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 pay for the RFA procedure.  Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found according to the literature, sacral lateral nerve branch blocks and/or 
ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered 
experimental and investigational. Radiofrequency ablation for denervation, whether performed using 
traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, 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 the RFA procedure have not been met. Therefore, we decided that the Plan does 
not have to pay for the right-sided radiofrequency ablation (RFA) of the sacral joint nerves and related 
outpatient hospital services provided on April 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on April 19, 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 36248 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 36248 is selective catheter placement, arterial system; 
additional second order, third order, and beyond, abdominal, pelvic, or lower extremity artery branch, within a 
vascular family (List in addition to code for initial second or third order vessel as appropriate). 
 
We find that CPT code 36248 is not supported in the medical record. Specifically, there is no documentation of 
selective catheter placement into the arterial system. 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 April 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy services provided to you from May 4, 
2021, to June 8, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the use of infrared therapy devices and any 
related accessories is not reasonable and necessary.  
 
We looked at the file and Medicare rules. Per NCD 270.6, the requested infrared therapy services are not 
covered.  
 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 infrared therapy services provided to you from 
May 4, 2021, to June 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (K0554). 
 
You asked the Plan to pre-approve a Freestyle Libre. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for coverage for a continuous glucose monitor 
have not been 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 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 
Freestyle Libre have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre continuous glucose monitor (K0554).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) provided July 20, 2021. 
 
You asked the Plan to pay for the comprehensive oral exam. You say that you got a new dentist because you 
were dissatisfied with your previous dentist. The Plan denied your request. The Plan says you have exceeded 
the frequency limit for this service. 
 
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. The Plan covers the 
comprehensive oral exam once every three plan years.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive oral 
exam was previously covered on January 8, 2020. Based on this information, we decided that the Plan's frequency limit for coverage of the comprehensive oral exam has been exceeded. Therefore, we decided that 
the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) 
provided July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the photochemotherapy services provided on September 16, 
2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that you obtained a back-dated authorization. The 
Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 photochemotherapy services provided on September 16, 2020, by an out-of-
network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray examination (71045) provided on July 18, 2021. 
 
You asked the Plan to pay for x-ray 71045. You say that you are appealing with records to support this level of 
service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because 
this code has a procedure-to-procedure (PTP) edit with code 36573 and is not separately payable without an 
appropriate modifier. 
 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 x-ray 
71045 is a column II code to column I code 36573. 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 an x-ray examination (71045) provided on July 18, 2021.