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

 
We decided that the Plan does not have to pay for an office visit provided on March 3, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this is not a network provider with the Plan and the services were not 
referred by a network provider or rendered in an in-network facility. The Plan also says that they have also 
determined that these services are not urgent or emergent, nor were they approved in advance. 
 
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 an office visit provided on March 3, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 22, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services are covered and this 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 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 July 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a biventricular pacemaker (33229, 33225). 
 
You asked the Plan to pre-approve a biventricular pacemaker. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for coverage of 
the requested services have not been met. 
 
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 biventricular pacemaker. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is insufficient documentation to support the medical necessity for removal 
of the single-chamber pacemaker and replacement with a biventricular pacemaker. 
 
 
 
 
 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 biventricular pacemaker have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a biventricular pacemaker (33229, 33225).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary as you believe it is your only option for low-back pain relief. The Plan denied your 
request. The Plan says an epidural steroid injection does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 epidural steroid injection. Our 
reviewer says that an epidural steroid injection is not medically necessary. Our physician reviewer found that 
the documentation does not reveal a clear history and physical examination of lumbar radiculopathy. The 
documentation does not reveal failure to respond to four (4) weeks of noninvasive conservative care. 
 
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 epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on October 13, 
2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that the bill should have been paid by 
the Plan. The Plan denied your request. The Plan says the proper copayment was applied for the out-of-network 
services. 
 
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 $40 
copayment for each out-of-network Medicare-covered primary care doctor visit.  
 
  You have been asked to pay a $40 copayment for the office visit. The office visit 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 October 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crutch substitute lower leg platform. 
 
You asked the Plan to pre-approve crutch substitute lower leg platform. You say that you will be having 
surgery on your foot and cannot put any weight on it for 2 weeks, so you cannot use normal crutches. The Plan 
denied your request. The Plan says the denial of authorization for this item is correct, because a crutch 
substitute lower leg platform is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that crutch substitute lower leg platforms are not 
covered by Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of crutch substitute lower leg platform have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crutch substitute lower leg platform.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device. 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that this device is medically necessary. 
The Plan denied your request. The Plan says this device is not medically reasonable and 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 the CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that at issue is the medical appropriateness and necessity of implantation of the 
wireless pulmonary artery pressure monitoring system (CardioMEMS) for management of congestive heart 
failure (CHF) in this patient. The CardioMEMS device was approved by the Food and Drug Administration 
(FDA) in 2014 and consists of a sensor device placed in the pulmonary artery to allow measurement of 
pulmonary artery pressure in the management of patients with CHF. The clinical study on which FDA approval 
was based showed improved clinical outcomes and decreased hospitalizations in patients in whom the 
CardioMEMS system was implanted, reflecting a patient population with preserved ejection fraction and was 
somewhat limited in scope. Subsequent follow-up studies remain encouraging and suggest an improvement in heart failure symptoms with the use of the device. In addition, published expert opinion in the cardiology 
literature is supportive of the clinical usefulness of CardioMEMS.  Nonetheless, there remains a dearth of 
randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be 
considered medically appropriate and necessary in this patients 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 the CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan (70450) provided on February 17, 2022. 
 
You asked the Plan to pay for the CT scan (70450). You say that the enrollee had multiple exams on this date 
of service and the attached reports support the level of service. You say that the claim should be reconsidered 
for processing. The Plan denied your request. The Plan says an appropriate modifier was not billed with this 
code edit.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the CT scan (70450) provided on February 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid, digital, binaural, behind the ear (V5261) 
provided January 14, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON hearing aids. You say that you were told that this provider is part of the 
Plan's network. The Plan denied your request. The Plan says the hearing aids are not covered because they were 
purchased OON. The Plan also says they have researched their communication systems and are unable to locate 
any calls made by the enrollee to verify coverage prior to the services being rendered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are purchased through the Plans specified network hearing aid provider.  
 
We looked at the file and the Plan's rules. In this case the hearing aids were purchased OON. Based on this 
information, we decided that the Plan's rules for coverage of the OON hearing aids have not been met. 
Therefore, we decided that the Plan does not have to pay for the hearing aid, digital, binaural, behind the ear 
(V5261) provided January 14, 2022, by an out-of-network (OON) provider.  
 
Your complaint about potentially receiving misinformation from a plan representative is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiography (93350). 
 
You asked the Plan to pre-approve a transthoracic echocardiography. You say that the requested service is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for 
coverage of the requested service have not been met. 
 
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 transthoracic echocardiography. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee's pre-test probability for an abnormal test is low and there is no 
documentation that the electrocardiogram shows an uninterpretable pattern. There is no evidence provided that 
would support the need for a repeat stress echocardiogram. 
 
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 transthoracic echocardiography have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a transthoracic echocardiography (93350).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the continuity of care offered at a rehabilitation 
hospital will give the enrollee the best opportunity to improve function and return to baseline. The Plan denied 
your request. The Plan says the enrollee does not meet the criteria for approval of IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found the enrollee was admitted to an acute hospital after a fall. There are no complex 
nursing or rehabilitation needs. While the enrollee has a need for physical or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. While the enrollee may benefit from 
continued physical and occupational therapy, rehabilitation needs can be safely provided in a lower intensity 
and alternate setting such as in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the specialist office visit. You say that you are unhappy with the in-network 
providers and would like to see an OON provider. The Plan denied your request. The Plan says there are 
multiple in-network providers that the enrollee can see that provide the same quality of care as an OON 
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 
a specialist office visit 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 a foot longitudinal/metatarsal support to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a foot longitudinal/metatarsal support. You say that you would like to 
appeal the denial of the claim. The Plan denied your request. The Plan says the provider is out-of-network and 
it was determined these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a foot longitudinal/metatarsal support to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to reduce the copayment for the PT services. We also decided that the Plan does 
not have to fully waive the copayment for the PT services.  
 
You asked the Plan to reduce the copayment for the PT services. You say that you did not ask for or authorize 
the services. The Plan says that you have been charged the correct cost sharing 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 $25 
copayment for each therapy visit. The Plan says that you must pay $99.99, which is less than the $300 copayment for an outpatient hospital visit. 
Based on the Plan contract, however, you cannot be asked to pay more than a $25 copayment for the PT 
services. Therefore, we decided that the Plan has to reduce the $99.99 copayment for the PT services to $25. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99024) provided on October 5, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99024 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99024 is not separately payable. 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 
(99024) provided on October 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided on March 3, 2022. 
 
You asked the Plan to pay for a wrist-hand orthosis. You say that the item at issue was a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in 
the enrollees medical record adequately supports the medical necessity for the item. 
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The available medical documentation does not discuss the item at issue. The record shows that the 
Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that 
the Plan does not have to pay for a wrist-hand orthosis (L3916) provided on March 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray exam of the chest (71045) provided on February 
18, 2022. 
 
You asked the Plan to pay for the x-ray. You say that this service was necessary and was billed appropriately. 
The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to 
Procedure (PTP) edit exists between 71045 and 32555. This PTP edit has a modifier indicator of 1, meaning 
modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed appropriately by Medicare coding regulations. 
 
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 32555 is a column II code to column I code 71045. This claim has not been billed with an appropriate modifier to 
bypass the edit. While these services were performed by two different physicians, both physicians are part of 
the same provider group/facility and have the same specialty/primary taxonomy code. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for the x-ray exam of the chest (71045) provided on February 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Stereotactic biopsy, aspiration, or excision, including burr 
hole(s), for intracranial lesion (61750) provided January 14, 2022. 
 
You asked the Plan to pay for the surgical procedure. You say that the claim denied for medical records. You 
have uploaded the medical records for the date of service 01/14/2022. The Plan denied your request. The Plan 
says procedures with a status indicator of 1 are not eligible for assistant at surgery reimbursement. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 61750. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
surgical procedure have not been met. Therefore, we decided that the Plan does not have to pay for Stereotactic biopsy, aspiration, or excision, including burr hole(s), for intracranial lesion (61750) provided January 14, 
2022.