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

 
We decided that the Plan does not have to pre-approve catheter placement in coronary artery(s) for coronary 
angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and 
interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, 
when performed (93458). 
 
You asked the Plan to pre-approve left heart catheterization. You say that you disagree with the denial and have 
attached records for review. The Plan denied your request. The Plan says the left heart catheterization does not 
meet the requirements for approval. 
 
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 left heart catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found at issue is the medical necessity for performance of cardiac catheterization for 
evaluation of chest pain. The enrollee has not had a stress test or coronary CT scan. Guidelines do not support a 
need for this invasive study in this setting. As a result, at this time cardiac catheterization would not be 
considered medically appropriate and necessary in this enrollee's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of left heart catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve catheter placement in coronary artery(s) for coronary angiography, including 
intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart 
catheterization including intraprocedural injection(s) for left ventriculography, when performed (93458).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on April 27, 2022. 
 
You asked the Plan to pay for the outpatient service. You say that the service should be covered. The Plan 
denied your request. The Plan says the claim was processed 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 99214 is Office or other outpatient visit for the evaluation 
and management of an established patient, which requires at least 2 of these 3 key components: A detailed 
history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting 
problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient 
and/or family. 
 We find that CPT code 99214 is not supported in the medical record. Specifically, this code is defined as 
outpatient, but the claim was billed with an inpatient Place of Service code. Based on this information, we 
decided that Medicare rules for coverage of the outpatient service have not been met. Therefore, we decided 
that the Plan does not have to pay for the office visit (99214) provided on April 27, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the cervical spine. 
 
You asked the Plan to pre-approve an MRI of the cervical spine. You say that the services are necessary. The 
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not 
been met. 
 
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 an MRI of the cervical spine. Our 
reviewer says that the services are medically necessary. Our physician reviewer found based on the medical 
records provided there is documentation that the MRI scan at issue in this case meets all Medicare criteria for 
medically reasonable and necessary for the enrollee. Provided records document persistent neck, shoulder and 
back pain from February 2022 through August 2022 despite treatment with meloxicam, cyclobenzaprine and 
acetaminophen as well as steroid injections and physical therapy treatments from June through August 2022. 
As of August 16, 2022, at the time of the initial MRI request, the enrollee had completed at least six to nine 
weeks of conservative treatment with persistent symptoms of neck pain. 
 
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 MRI of the cervical spine have been met. Therefore, we decided that the Plan 
has to pre-approve a magnetic resonance imaging (MRI) of the cervical spine.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair van transportation services provided on June 
21, 2022. 
 
You asked the Plan to pay for the wheelchair van transportation services. You say that you would like this 
claim reprocessed and approved for payment. The Plan denied your request. The Plan says these services are 
not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for the wheelchair van transportation services provided on June 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (POV) (E1230). 
 
You asked the Plan to pre-approve a motorized scooter. You say that you disagree with the denial and would 
like the requested scooter approved. The Plan denied your request. The Plan says outreach to your provider 
shows that an assessment of your home was not completed. A power wheelchair or scooter may be appropriate 
for you if all criteria is met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that you do not have a mobility deficit that impairs your participation in MRADLs. The file also 
shows that a home evaluation, a report showing you are able to safely use the wheelchair, a seating and 
mobility evaluation and a complete evaluation of your mobility, strength, range of motion and skin integrity 
have not been completed. This means that Medicare rules for coverage of a POV have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a power operated vehicle (POV) (E1230).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve colon surgery to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the OON colon surgery. You say that the enrollee already has the surgery 
scheduled and any delay would greatly result in a decline in her health. The Plan denied your request. The Plan 
says the medically necessary services are available with a participating provider. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services with an OON provider. Therefore, we decided that the Plan does not have to 
pre-approve colon surgery to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot inserts. 
 
You asked the Plan to pre-approve foot inserts. You say that the enrollee needs orthotic shoes and toe fillers. 
The Plan denied your request. The Plan says the foot inserts are not part of a covered brace. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
The file shows that left and right foot inserts, L3031, were requested. The records do not show that the inserts 
are being requested as part of a covered brace. Based on this information, we decided that the Medicare rules 
for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve foot inserts.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that you have had a dry cough for 4 years. The Plan 
denied your request. The Plan says services could be provided by a participating provider. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
physician services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from June 17, 2021, 
to June 24, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services as originally billed. You say that the services have 
been billed correctly. The Plan denied your request. The Plan says medical records to support the inpatient care 
as originally billed were not received despite multiple outreach attempts. 
 
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 inpatient hospital services as 
originally billed have been met. The Plan sent several requests for medical records to provide evidence that the 
services were billed correctly. A response to these requests was not returned. Therefore, we decided that the 
Plan does not have to pay for the inpatient hospital services provided from June 17, 2021, to June 24, 2021, at 
the Diagnosis Related Group (DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided 
May 16, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that the provision of F1CDx to the enrollee meets 
the requirements of the NCD and has been determined by CMS to be reasonable and necessary for the management of the enrollee's advanced cancer. The Plan denied your request. The Plan says does not meet 
Medicare NCD/LCD criteria. 
 
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 0037U is targeted genomic sequence analysis, solid organ 
neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, 
gene rearrangements, microsatellite instability and tumor mutational burden. 
 
We find that CPT code 0037U is not supported in the medical record. Specifically, the date of service of the 
test/service must be the date the specimen was collected. The specimen was collected on 04/14/2022, received 
on 05/06/2022 and the date billed on the claim is 05/16/2022. Also, the next generation sequence testing (NGS) 
testing panel performed included testing for the FANCC gene. Testing for this gene is not a Medicare benefit 
and is statutorily excluded service. In addition to single gene testing, panels that include the FANCC gene are 
statutorily excluded service. Based on this information, we decided that Medicare rules for coverage of the 
genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
FoundationOne CDx (F1CDx) test (0037U) provided May 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 22, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. 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 June 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for oxygen equipment on June 16, 2022. 
 
You asked the Plan to waive the coinsurance for oxygen equipment. You say that you want to appeal the 
amount being 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 20% 
coinsurance for all other covered durable medical equipment (DME) items. Covered items include, but are not 
limited to wheelchairs, crutches, powered mattress systems, diabetic supplies, hospital beds ordered by a 
provider for use in the home, IV infusion pumps, speech generating devices, oxygen equipment, nebulizers, 
and walkers. The provider billed in the amount of $3,705.27 and the allowed amount is $1,300.68. $1,300.68 x 
20% = $260.14. Therefore, resutls in the total cost sharing amount of $260.14. 
 
 
 
 
 You have been asked to pay a 20% coinsurance for oxygen equipment. This item/service falls within the 
Durable medical equipment (DME) and related 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 coinsurance for oxygen equipment on June 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an open sacroiliac joint fusion. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has difficulty walking. The 
Plan denied your request. The Plan says there is no documentation of instability, fracture, or tumor. 
 
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 requested services. Our physician 
reviewer found that the enrollee has a degenerative lumbar condition. There is no evidence of sacroiliac joint 
instability, fracture, or lesion. A sacroiliac joint fusion for back pain is considered experimental. Therefore, the 
request is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an open sacroiliac joint fusion.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant 
(D6010), custom fabricated abutment includes placement (D6057) and abutment supported porcelain/ceramic 
crown (D6058). 
 
You asked the Plan to pre-approve dental services. You say that you need the requested services because of 
issues with your dentures. You also say it is painful to chew and eat. The Plan denied your request. The Plan 
says this service is not covered under your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Surgical placement of implant 
body: endosteal implant (D6010), custom fabricated abutment includes placement (D6057) and abutment 
supported porcelain/ceramic crown (D6058) are not covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested surgical placement of 
implant body: endosteal implant (D6010), custom fabricated abutment includes placement (D6057) and 
abutment supported porcelain/ceramic crown (D6058) are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pre-approve surgical placement of implant body: 
endosteal implant (D6010), custom fabricated abutment includes placement (D6057) and abutment supported 
porcelain/ceramic crown (D6058).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialist visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve specialist visit. You say that you have been ill for 8 months and need to see 
the specialist. The Plan denied your request. The Plan says the service can be provided by an in-network 
provider. 
 
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 
specialist visit to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on July 26, 2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for the psychotherapy services 
provided on July 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
request does not meet the requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under 
certain medical indications.  
 
 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 requested services. Our physician 
reviewer found that the enrollee has chronic axial low back pain. She had one set of diagnostic medial branch 
blocks (MBBs) on November 2, 2022, which produced 80% pain relief. The coverage criteria require 2 sets of 
diagnostic blocks, each of which produces 80% pain relief. This is not documented. Therefore, the request is 
deemed 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation.