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

 
We decided that the Plan does not have to pay for the radiology services provided on June 5, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the radiology services. You say that you are a participating provider and would 
like the claim paid. The Plan denied your request. The Plan says the rendering and referring providers are both 
OON providers and there was no approved 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 the radiology services provided on June 5, 2022, 
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 MyoPro Motion G orthotic device. 
 
You asked the Plan to pre-approve MyoPro Motion G. You say that this is supported as an appropriate 
intervention. The Plan denied your request. The Plan says studies have not proven that this is helpful for 
treatment of the enrollee's condition. 
 
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 MyoPro Motion G. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found current clinical guidelines designate robotic therapy to be of uncertain utility 
compared with conventional upper limb exercise therapies with unproven benefit in the home environment. 
The records do not clarify why this device is the most appropriate treatment for the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MyoPro Motion G have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro Motion G orthotic device.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service July 15, 
2022. 
 
You asked the Plan to pay for procedure code 76700. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for 
code 93976. 
 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 76700 
is a column II code to column I code 93976. 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 76700 billed for date of service July 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an advance foot/ankle prosthetic. You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee does not have level 3 ambulation. 
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses 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 a replacement prosthesis due to weight gain was requested. A level 3 ambulator has the 
ability or potential for ambulation with variable cadence.  Typical of the community ambulator who has the 
ability to traverse most environmental barriers and may have vocational, therapeutic or exercise activity that 
demands prosthetic utilization beyond simple locomotion. In this case, the documentation does not indicate the 
enrollee is able to ambulate at a K3 functional level. The documentation indicates the enrollee requires assistive 
devices for ambulation and mobility. The requested advanced foot/ankle system 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 advance foot/ankle prosthetic.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for the laboratory services. We decided that the Plan 
does not have to waive the copayment for the laboratory services.  
 
You asked the Plan to waive the copayment and coinsurance for laboratory services. You say that this should 
be covered. The Plan says that this cost sharing was charged correctly. 
  We decided that the Plan has to waive the coinsurance for the laboratory services.  
 
The Plan says 50% coinsurance and a $65 copayment applies to the laboratory services. Coinsurance only 
applies to laboratory services provided at an out-of-network outpatient hospital. The Place of Service on the 
claim shows the laboratory services were provided at an office. Therefore, we decided that the Plan has to 
waive the coinsurance for the laboratory services. 
 
We also decided that the Plan does not have to waive the $65 copayment for the laboratory 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 $65 
copayment for laboratory services at an out-of-network primary care physicians office or specialists office 
office. Therefore, we decided that the Plan does not have to waive the $65 copayment for the laboratory 
services. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve budesonide capsules. 
 
You asked the Plan to pre-approve self-administered drug. You say that you are appealing this denial. The Plan 
denied your request. The Plan says this drug is not covered by Medicare Part B and the Plan does not 
administer the enrollee's Medicare Part D prescription drug benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve budesonide capsules.  
 
Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller for a power wheelchair 
(E2377, E2313, E2311). 
 
You asked the Plan to pre-approve the expandable controller for a power wheelchair. You say that this 
equipment is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that expandable controllers are covered when 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 the expandable controller for a power wheelchair. Our reviewer says that the expandable controller is not medically necessary. Our physician 
reviewer found the records document that the enrollee has sufficient upper extremity strength and function to 
operate the wheelchair's power options with their own switches.  
 
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 expandable controller for a power wheelchair have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an expandable controller for a power wheelchair (E2377, 
E2313, E2311).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service June 12, 
2022. 
 
You asked the Plan to pay for procedure code 86077. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed. 
 
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 86077 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 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service June 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laser cataract surgery. 
 
You asked the Plan to pre-approve laser cataract surgery. You say that you suffer from anxiety and are very 
nervous about having surgery on the eye with regular cutting. You say that you have a lot of health issues that 
you take medication for and that it is better for your health and emotion state for the procedure to be done by 
laser. The Plan denied your request. The Plan says conventional cataract surgery will be covered, but that the 
extra cost for laser-assistance is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that additional payment is not made for bladeless 
laser cataract surgery. Enrollees must pay for this upcharge out of pocket if provided. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laser cataract surgery have not been met. Therefore, we decided that the Plan does not have to pre-
approve laser cataract surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that it is medically necessary for the enrollee 
to receive LTACH services. The Plan denied your request. The Plan says the Medicare guidelines for LTACH 
admission were not met and the enrollee is receiving the care that they need in the current hospital that they are 
at. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
  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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to be improving but still unstable and requires additional 
acute care services that can safely be provided at the current facility until more stable and appropriate for 
transfer. The patient does not require services at the LTACH that are not already available at the current 
facility. There are no services at the LTACH that the enrollee requires that are not already available and 
covered at the current facility. Transfer to the LTACH is not medically necessary as the enrollee is not yet 
stable and as it would not be clinically advantageous. Completion of treatment at the current facility is 
recommended. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit provided on August 2, 2022. 
 
You asked the Plan to pay for the office visit. You say that the enrollee was referred by an in-network provider. 
The Plan denied your request. The Plan says that the services do not match what was approved. 
 
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. 
 
We looked at the file and the rules. The Plan says that an authorization exists, but the service did not match 
what was approved. The Plan has not provided the authorization to show that criteria was not met for the 
services at issue. The Plan has not made reasonable and diligent efforts to gather and forward to us information 
regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for the office visit 
provided on August 2, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan provided on July 12, 2022. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you should not be responsible to pay 
this because you were not told you would have a copayment. 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 enrollees must pay a 
$200 copayment for a CT scan provided in-network.  
 
 
 You have been asked to pay $102.08 for a CT scan. This amount is less than the standard cost sharing amount. 
This item/service falls within the advanced imaging services benefit category. This means that you have been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to 
waive the copayment for a CT scan provided on July 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac contractility modulation (CCM).  
 
You asked the Plan to pre-approve CCM. You say that the records provided support the need for the requested 
services. The Plan denied your request. The Plan says the CCM device is not medically 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 CCM. Our reviewer says that CCM is 
not considered medically reasonable and necessary in this case. Our physician reviewer found while the clinical 
studies led to Food and Drug Administration (FDA) approval in 2019, CCM remains the subject of multiple 
studies examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify 
clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical 
outcomes and benefit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CCM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve cardiac contractility modulation (CCM).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 17, 2022, to 
February 15, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the rules for 
payment have not been 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. 
 
We looked at the file and the rules. The admission date on the notice of admission is inconsistent with the 
admission date on the 30-day period of care claim. Based on this information, we decided that Medicare rules 
for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay 
for the home health services provided from January 17, 2022, to February 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided March 16, 2022, to 
March 18, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says these services could have been provided at an 
observation level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found there is no documentation of uncontrolled co-morbidities and no documentation of 
procedural/post-procedure complications, which necessitated a prolonged (i.e. two midnight) stay following the 
catheter placement.  The enrollee could have been managed as an outpatient/on observation status. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided March 16, 2022, to March 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluoroscopic guidance for needle placement (77002) 
provided on June 6, 2022. 
 
  You asked the Plan to pay for the fluoroscopic guidance for needle placement (77002). You say that procedure 
code 77002 was billed with modifier 26 to indicate the professional component. You say that the attached 
records should be reviewed, and the claim reprocessed for payment. The Plan denied your request. The Plan 
says procedure code 77002 was billed without an appropriate primary code. 
 
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 77002 
is an add-on code and has not been billed with an appropriate primary procedure 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 fluoroscopic guidance for needle placement (77002) provided on June 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant surgeon services on knee arthroscopy surgery 
(29880 and 29879) provided on June 2, 2022. 
 
You asked the Plan to pay for assistant surgeon services on knee arthroscopy surgery. You say that the records 
support these services. The Plan denied your request. The Plan says an assistant surgeon was not medically 
necessary. 
 The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary 
are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment 
restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to 
establish medical necessity. In this case, you billed assistant surgery services for Current Procedural 
Terminology (CPT) codes 29880 and 29879. The Medicare Fee Schedule Database contains a surgical 
indicator of 0 for this procedure.  
 
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 assistant surgeon services on knee 
arthroscopy surgery. Our reviewer says that the assistant surgeon services are not supported in the records. Our 
physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of the assistant surgeon. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of assistant surgeon services on knee arthroscopy surgery have not been met. 
Therefore, we decided that the Plan does not have to pay for assistant surgeon services on knee arthroscopy 
surgery (29880 and 29879) provided on June 2, 2022.