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

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array, epidural (CPT code 63650). 
 
You asked the Plan to pre-approve the service. You say that the enrollee has trouble with daily living skills. 
Member has begun to show signs of it affecting his daily living as well as his mobility to maneuver about with 
walking as it causes significant chronic pain. The Plan denied your request. The Plan says the enrollee's request 
is not medically necessary because their records show they do not have screening and treatment performed by 
physical therapy or psychology. 
 
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 service. Our physician reviewer 
found the enrollee does not have an evidence-based indication for a spinal cord simulator (SCS) trial. The 
enrollee also has not had a psychological evaluation and there is no documentation of a surgical consultation. 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (CPT code 63650).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 3, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 procedure code 70450 billed for date of service May 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hepatobiliary system imaging (78226). 
 
You asked the Plan to pre-approve a hepatobiliary system imaging. The Plan denied your request. The Plan 
says the request is not medically necessary because the current standard of care to determine gallbladder 
disease would be to perform an ultrasound as first-line imaging. The Plan also says that there is no 
documentation showing that an ultrasound was performed to determine the presence of gallstones or 
gallbladder disease. 
 
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 hepatobiliary system imaging. Our 
reviewer says that the requested hepatobiliary system imaging is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the chart notes say you were diagnosed with gallstones 
and surgery was recommended. On June 10, 2022, an order was placed for a complete ultrasound, but no report 
is included. Our reviewer found that a hepatobiliary scan with Cholecystokinin challenge should only be done 
if there is no impacted gallstone or sonographic evidence of cholecystitis. Our physician reviewer also found 
that since there is no report of an ultrasound in the records, the medical necessity of the requested nuclear 
medicine study is not supported. 
 
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 hepatobiliary system imaging have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a hepatobiliary system imaging (78226).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for contact lenses (V2531 x2) provided on May 19, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for contact lenses. You say that the lenses were medically necessary. The Plan 
denied your request. The Plan says the provider is out-of-network, and there was no pre-authorization. 
 
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 contact lenses (V2531 x2) provided on May 19, 
2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (70553) provided on April 2, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was billed 
with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that for all services (with two (2) exceptions), the 
POS code to be used by the physician or other supplier will be assigned as the same setting in which the 
beneficiary received the face-to-face service. The two exceptions are for enrollees who are registered hospital 
inpatients or outpatients, in which case, the inpatient or outpatient hospital POS code would be reported 
regardless of where the face-to-face service takes place.  
 
We looked at the file and Medicare rules. In this case, the services were billed with an outpatient POS code 
(22). However, the records show that the enrollee was an inpatient when the service were provided. This means 
that the services must be billed with an inpatient POS code. 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 (70553) provided on April 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need to get to the strength you had. You state 
you were able to do things on your own. The Plan denied your request. The Plan says the stay is not medically 
necessary based on IRF criteria. 
 
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 there is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 2, 2022, to March 30, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 February 2, 2022, to 
March 30, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for extraperitoneal procedures in lower abdomen, 
including urinary tract (00860) provided June 7, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that the claim was denied as untimely filing, but 
you filed the claim within timely filing. You have attached the proof of timely filing for review. The Plan 
denied your request. The Plan says the Plan is secondary and the claim must be submitted to the primary Plan 
where there is primary coverage for the services. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, another payer as the 
primary Plan. As the secondary insurer, the Plan cannot be held responsible for the anesthesia services until the 
primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to 
pay for anesthesia for extraperitoneal procedures in lower abdomen, including urinary tract (00860) provided 
June 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology imaging provided on December 7, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for radiology imaging. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 radiology imaging provided on December 7, 2021, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the stationary and portable oxygen concentrators. 
 
You asked the Plan to pre-approve the requested oxygen equipment. You say that you need oxygen and feel 
that this denial is wrong. The Plan denied your request. The Plan says that 36 rental payments have been made 
for oxygen. No more payments are required. 
 
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 notes that this request cannot be approved since the rental period for 
the equipment is over and no further payments can be made. The Plan indicates that the rental began on 
September 25, 2017; however, no evidence was provided to support this. It is not clear if the network provider 
making this request is the same provider which furnished the oxygen rental beginning in 2017, and there is no 
evidence that 36 payments were made by the Plan for this equipment. Additionally, as September 25, 2022, 
would be 5 years from the purported date the equipment was received, Medicare rules indicate that the enrollee 
would be able to elect new equipment. It is not clear from the documentation if this is what the network 
supplier was asking to be approved. We sent a request to the Plan asking for clarification of these items, and no 
response was received. As we cannot confirm the date the equipment was originally provided and there is no 
clarity as to whether this denial would interrupt access to the oxygen equipment, we find that the denial is not 
supported. Therefore, we decided that the Plan has to pre-approve the stationary and portable oxygen 
concentrators.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81161 billed for date of service November 5, 
2021. 
 
You asked the Plan to pay for procedure code 81161. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 81161 is bundled into payment for code 81413. 
 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 81161 
is a column II code to column I code 81413. 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 procedure code 81161 billed for date of service November 5, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing provided on February 23, 2022. 
 
You asked the Plan to pay for the testing services. You say that the test is more reliable than urine-based 
detection test. The Plan denied your request. The Plan says the test is not covered. 
 
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 testing services. Our physician reviewer 
found that the enrollee has recurrent, low grade superficial bladder cancer. A cystoscopy, ureteroscopy, 
possible biopsy and upper tract imaging will still be necessary regardless of the results of CxBladder testing. 
Urinary biomarker tests such as CxBladder give significant false-negative results in those with urothelial 
cancer and are subject to false-positive results in others. Accuracy is poor for low-stage and low-grade tumors. 
The records do not show that the results of the test would impact clinical management to improve the enrollee's 
outcome. 
 
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 testing services have not been met. Therefore, we decided that the Plan does 
not have to pay for the CxBladder testing provided on February 23, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a Saebo Step ankle-foot orthosis (AFO) purchased on April 11, 2022. 
 
You asked the Plan to pay for Saebo Step AFO. You say that you need this orthosis. The Plan denied your 
request. The Plan says that the denial of payment for this item is correct, because this provider is out-of-
network with the Plan. 
 
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 claims that a Saebo Step AFO is not covered when obtained from an 
out-of-network provider. However, based on your contract with the Plan, a Saebo Step AFO is covered when 
obtained from an out-of-network provider and has no particular referral or authorization requirement for 
coverage. Your treating physician say that this item is medically necessary for you. The Plan has provided no 
other rationale or evidence to support their denial. Therefore, the Plan has not shown that its decision to deny 
payment for this item is correct or justified. Therefore, we decided that the Plan has to pay for a Saebo Step 
ankle-foot orthosis (AFO) purchased on April 11, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you just had surgery and are unable to walk on your 
own. You state that you have been advised therapy is the best option for you. The Plan denied your request. 
The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 there are no specific exceptions of alternative clinical concerns documented; thus, 
IRF criteria have not been met. 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0394T billed for date of service October 15, 
2021. 
  You asked the Plan to pay for procedure code 0394T. You say that the medical notes justify billing 0349T 
because the enrollee received treatments at 2 separate sites. You say that only one unit was paid, and additional 
payment should be made. The Plan denied your request. The Plan says payment for code 0394T is bundled into 
payment for code 77401. 
 
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 0394T 
is a column II code to column I code 77401. This code 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 procedure code 0394T billed for date of service October 15, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tecentriq. 
 
You asked the Plan to pre-approve Tecentriq. You say that the enrollee's systemic disease is well-controlled on 
maintenance Tecentriq and although she had progressive disease in her brain, which was treated with radiation, 
her systemic disease has remained stable. You say that the enrollee should continue with maintenance 
Tecentriq. The Plan denied your request. The Plan says the requested drug is experimental/investigational. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Tecentriq. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the requested use of Tecentriq is not 
FDA-approved for the enrollee's diagnosis, as the enrollee has progression of disease in the brain with more 
than 2 sites and imaging from June 28, 2022, shows possible progression. Repeat imaging would be needed. 
The use of the requested drug in this instance is not supported by one of the major drug compendia or by 
clinical research that appears in a CMS-approved medical journal.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tecentriq have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Tecentriq.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 13, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 procedure code 70450 billed for date of service April 13, 2022.