Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive copayments for physical therapy visits provided from 
September 29, 2021, to November 1, 2021. 
 
You asked the Plan to waive copayments for physical therapy visits. You say that you were told the physical 
therapy was covered and did not know it was $40 every time you went. You also say that if you had known you 
would not have gone, and you have cancelled all future appointments. The Plan denied your request. The Plan 
says 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 $40 
copayment for in-network physical therapy visits.  
 
 You have been asked to pay a $40 copayment for each physical therapy visit you had on September 29, 2021, 
October 1, 2021, and November 1, 2021. Physical therapy visits fall within the Outpatient Rehabilitation 
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 copayments for physical therapy visits 
provided from September 29, 2021, to November 1, 2021.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve an excision of benign lesion (11442). We decided that the Plan 
does not have to pre-approve an intermediate repair of wounds (12051).  
 
You asked the Plan to pre-approve an excision of benign lesion and an intermediate repair of wounds. You say 
that the requested services are a medical necessity for the enrollee. The Plan says that rules for coverage have 
not been met because the requested services are cosmetic in nature. 
 
The Plan follows Medicare rules. Medicare rules say that removal of benign skin lesions is not considered 
cosmetic when symptoms or signs which warrant medical intervention are present. The rules also 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 an excision of benign lesion and an 
intermediate repair of wounds. Our reviewer says that an excision of benign lesion is medically reasonable and 
necessary in this case; however, an intermediate repair of wounds is not medically reasonable and necessary. 
Our physician reviewer found that the enrollee has a facial mass that was present for years and was 
asymptomatic. The record indicates that work-up revealed the mass to be most likely benign. The record as 
provided does not indicate the presence of an enumerated condition for coverage of procedure code 11442; 
however, based upon the lesion's location relative to the buccal branch of the facial nerve, the presence of a 
sign exists that renders the procedure noncosmetic in nature. The elements of the coverage criteria for 
procedure code 11442 are satisfied. However, the record as provided does not support the need for procedure 
code 12051: "Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm 
or less." 
 
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 excision of benign lesion have been met. However, Medicare rules for 
coverage of an intermediate repair of wounds have not been met. 
 
Therefore, we decided that the Plan has to pre-approve an excision of benign lesion (11442). 
 
However, the Plan does not have to pre-approve an intermediate repair of wounds (12051). 
 
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 sales tax (S9999). 
 
You asked the Plan to pay for the sales tax. You say that the services should be covered. The Plan denied your 
request. The Plan says Medicare does not cover sales tax. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not reimburse separately for sales 
tax.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the sales tax have not been met. Therefore, we decided that the Plan does not have to pay for the 
sales tax (S9999).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, emergency 
transport (A0429), and ground mileage (A0425) provided on October 20, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the enrollee could have been safely transported by another type of 
motor vehicle. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same 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 pay for the ambulance services. Our reviewer says 
that the emergency ambulance services were not medically necessary. Our physician reviewer found the 
documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, 
private car, or other type of vehicle) were contraindicated for the enrollee. The documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-
equipped ambulance can provide for safe transport. The documentation does not support that the ambulance 
transport was medically reasonable and necessary, as defined by Medicare rules, for the enrollee. 
 
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 ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance service, basic life support, emergency transport (A0429), and ground 
mileage (A0425) provided on October 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies (K0553), 
provided on May 9, 2021. 
 
You asked the Plan to pay for the CGM supplies. You say that the items were medically necessary. The Plan 
denied your request. The Plan says the documentation submitted did not indicate the provider discussed the 
need for this item. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. 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 the 
continuous glucose monitor (CGM) supplies (K0553), provided on May 9, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a skilled nursing facility (SNF) stay 
provided from June 28, 2021, to July 22, 2021. 
 
You asked the Plan to waive the copayments for a skilled nursing facility stay. You say that you should not 
have to pay this since you did not receive proper nursing care. The Plan denied your request. The Plan says 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 contract says that enrollees must pay a 
$0 copayment for days 1-20 for a skilled nursing facility stay. The Plan contract also says there is a $184 
copayment for days 21-100. There is no charge for the day of discharge. 
 You are not being charged for the first 20 days you were in the SNF, from June 28, 2021, to July 17, 2021. You 
have been asked to pay a total of $736, which is a $184 copayment for days 21-24 of a skilled nursing facility 
stay ($184 copayment x 4 days = $736). There is no charge for the day of discharge. A skilled nursing facility 
stay falls within the Skilled Nursing Facility (SNF) Care 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 copayments for a skilled nursing facility (SNF) stay provided from June 28, 2021, to July 22, 2021.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the incision and drainage below fascia (28003) provided on 
October 9, 2021. 
  You asked the Plan to pay for the incision and drainage below fascia (28003). You say that modifier 59 was 
used to show 28003 is separate from the other codes. The Plan denied your request. The Plan says the criteria 
for reporting modifier 59 were not 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 28003 
is a column II code to column I code 28122. 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 incision and drainage below fascia (28003) provided on 
October 9, 2021.
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 
for the enrollee's condition. The Plan denied your request. The Plan says the requested device is considered 
experimental/investigational. 
 
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 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 congestive heart failure. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia (99100) provided on May 5, 2021. 
 
You asked the Plan to pay for the anesthesia (99100). You say that the services were rendered based on the 
patient condition and the procedure was essential to the patient's quality of health. The Plan denied your 
request. The Plan says bundled services are not eligible for separate payment. 
 
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 99100 is anesthesia for patient of extreme age, younger 
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). 
 
  We find that CPT code 99100 is not supported in the medical record. Specifically, CPT code 99100 has a status 
indicator of B. This means that CPT code 99100 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the anesthesia (99100) have not been met. 
Therefore, we decided that the Plan does not have to pay for the anesthesia (99100) provided on May 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulatory continuous glucose monitoring services 
(95250) provided on October 4, 2021. You asked the Plan to pay for the ambulatory continuous glucose monitoring services. You say that this 
procedure has been billed with a modifier that indicates it should be paid at a reduced rate. The Plan denied 
your request. The Plan says the claim has denied because the service exceeds the contracted maximum number 
of hours/days/units by this provider for this period 
 
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 95250 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 the 
ambulatory continuous glucose monitoring services have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulatory continuous glucose monitoring services (95250) provided on October 
4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99239) provided March 18, 2021. 
 You asked the Plan to pay for the physician services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the billed code has a bundled relationship with another code 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99239 
is a column II code to column I code 99223. 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 physician services (99239) provided March 18, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of home health speech therapy and 
physical therapy visits. 
 
You asked the Plan to pre-approve home health services. You say that these services continue to be medically 
necessary. The Plan denied your request. The Plan says the criteria for continued coverage of home health 
services have not been met. 
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be covered.  
 
The file does not show that you are homebound. Therefore, we decided that the Plan does not have to pre-
approve the continuation of home health speech therapy and physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that this service is considered experimental and investigational. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Current evidence 
based medical guideline and peer reviewed literature do not fully support the spinal decompression device 
procedure over the gold standard of lumbar laminectomy. There is a lack of large volume, long-term peer-
reviewed outcome studies to support the use of this device for this enrollees medical condition. Our physician 
reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that study results clearly demonstrate long-
term effectiveness and the durability of ablating the basivertebral nerve. You say that the evidence supports the 
use of the Intracept procedure as the primary treatment for chronic low back pain and the denial should be 
overturned. The Plan denied your request. The Plan says more research is needed to show safety and efficacy 
of the 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 pre-approve the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed to show safety and 
efficacy. 
 
  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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (CPT code 87633) provided on August 
5, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met. The genetic testing was 
not ordered/approved by the ordering provider. Therefore, we decided that the Plan does not have to pay for the 
laboratory service (CPT code 87633) provided on August 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection of sclerosant into multiple incompetent veins. 
 
You asked the Plan to pre-approve injection of sclerosant into multiple incompetent veins. You say that the 
requested procedure is medically necessary. The Plan denied your request. The Plan says the requested 
procedure is not medically necessary because the records show the enrollee does not have any abnormal venous 
flow after the recent varicose vein treatments. 
 
The Plan follows Medicare rules. Medicare rules say that they will consider coverage for invasive procedures 
as reasonable and necessary when documentation in the medical record includes a history, physical 
examination, CEAP clinical classification, and a venous duplex scan documenting reflux. 
 
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 injection of sclerosant into multiple 
incompetent veins. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer 
found the documentation does not support the medical necessity of the treatment in question.  
 It is documented that the enrollee is already status post bilateral greater saphenous vein ablation and bilateral 
lower extremity sclerotherapy. There is no further documentation that the enrollee is having ongoing symptoms 
attributable to varicose veins and is no description of untreated varicose veins. The most recent duplex studies 
demonstrate successful ablation of the greater saphenous veins bilaterally without evidence of ongoing reflux. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injection of sclerosant into multiple incompetent veins have not been met. 
Therefore, we decided that the Plan does not have to pre-approve injection of sclerosant into multiple 
incompetent veins.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that you are in severe pain. The Plan denied your 
request. The Plan says there are in-network providers available. 
 
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 
physical therapy services to be provided by an out-of-network (OON) provider.