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

 
We decided that the Plan does not have to pay for the psychotherapy services received from October 7, 2021, to 
November 4, 2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that you see this provider several times a 
year for depression. The Plan denied your request. The Plan says the services received are not payable. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the psychotherapy services received 
from October 7, 2021, to November 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for elevating wheelchair leg rests (K0195) provided on 
September 17, 2021. 
 
You asked the Plan to pay for elevating wheelchair leg rests. 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 durable medical 
equipment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that the RR modifier should be used when DME is to be rented. 
 
We find that CPT code K0195 is not supported in the case record. Specifically, the RR modifier was not billed with this rental item. Based on this information, we decided that Medicare rules for coverage of elevating 
wheelchair leg rests have not been met. Therefore, we decided that the Plan does not have to pay for elevating 
wheelchair leg rests (K0195) provided on September 17, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital admission and care provided from November 9, 
2021, to December 31, 2021, as a separate stay. 
 
You asked the Plan to pay for the inpatient admission and care. You say that the admissions were for unrelated 
issues for this severely ill and complex enrollee. The Plan denied your request. The Plan says that this new 
hospital stay cannot be approved as a separate stay. 
 
The Plan follows Medicare Rules. Medicare rules say that inpatient readmission is covered when medically 
necessary, and if the readmission did not result from a premature discharge from the same hospital. 
 
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 inpatient admission and care. Our 
reviewer says that the inpatient hospital admission and care were medically necessary. Our physician reviewer 
found the provided documentation supports that the readmission to the hospital was medically necessary for the 
enrollee in this case. The reviewer found that the provided documentation does not support that the readmission 
resulted from a premature discharge from the same hospital. The reviewer also found that the documentation 
does not support that the readmission was a result of circumvention of prospective payment system (PPS) by 
the same hospital. Therefore, the reviewer found that the inpatient admission and care were medically 
reasonable and necessary and should be paid separately.  
 
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 inpatient admission and care have been met. Therefore, we decided that the 
Plan has to pay for the inpatient hospital admission and care provided from November 9, 2021, to December 
31, 2021, as a separate stay.  
 
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 procedure code 19316-LT billed for date of service February 
3, 2022. 
 
You asked the Plan to pay for procedure code 19316-LT. You say that the operative report supports payment of 
this code. The Plan denied your request. The Plan says procedure code 19316-LT is not supported in the 
medical record. 
 
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 19316-LT is Mastopexy. 
 
 
 We asked our coder 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 procedure code 19316-LT. Our reviewer says that procedure 
code 19316-LT is not supported in the medical record. Our reviewer found the operative report does not 
describe a breast lift, or mastopexy, relocating the nipple and areola to higher position and removing excess 
skin below the nipple and above the breast crease. The physician makes an incision above nipple, in location to 
which the nipple will be elevated. Another skin incision is made around circumference of the nipple. Two skin 
incisions are made from the circular cute above the nipple to the fold beneath the breast, one on either side of 
the nipple, forming a keyhole shaped skin incision. This skin is cut away from the breast tissue and removed. 
The physician elevates the breast to its new position and closes the incision, excising any redundant skin in the 
fold beneath the breast". The procedure report documents: A concentric skin incision was made at the border 
of the areola followed by a second concentric incision. The epidermal ring was de-epithelialized and moved. 
The tissue overlying the tumor was under minded and the tumor was removed. The nipple areolar complex was 
repositioned to the center. The wound was closed with two layers of sutures the first layer with interrupted 
inverted Vycril 3.0 a, the second layer with 4.0 monocryl. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 19316-LT have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 19316-LT billed for date of service February 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99072) provided on December 29, 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 99072 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99072 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 
(99072) provided on December 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a limb prosthesis and leg fittings from 
August 23, 2021, to December 28, 2021. 
 
You asked the Plan to waive the coinsurance for a limb prosthesis and leg fittings from August 23, 2021, to 
December 28, 2021. You say that you should not have to be responsible for the coinsurance because the 
prosthesis never fit correctly so you returned it. The Plan denied your request. The Plan says you are 
responsible for a 20% coinsurance for prosthetic devices and related supplies. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Prosthetic Devices and Related Supplies.  
 
You have been asked to pay a 20% coinsurance for a limb prosthesis and leg fittings. A limb prosthesis and leg 
fittings falls within the Prosthetic Devices and Related Supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for a limb prosthesis and leg fittings from August 23, 2021, to December 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit services provided on February 7, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit services. You say that these services were medically necessary 
and should be paid. The Plan denied your request. The Plan says prior authorization was not obtained for these 
services rendered by 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 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 office visit services provided on February 7, 
2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services provided during gastric lap 
sleeve provided on October 11, 2021. 
 
You asked the Plan to pay for the gastric lap sleeve services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
 
 The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
assistant surgeon services provided during gastric lap sleeve provided on October 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5298) purchased on 
November 15, 2017. 
 
You asked the Plan to issue reimbursement for the hearing aids. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the hearing aids 
in this case are not payable as they were rendered by an out-of-network provider. 
 
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.  
 
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the hearing aids in this case were rendered by an out-
of-network provider. The Plan contract says that hearings aids must be ordered from the Plans network 
provider. Therefore, we decided that the Plan does not have to issue reimbursement for the hearing aids 
(V5298) purchased on November 15, 2017.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing coded 81238 provided on April 29, 
2021. 
 
You asked the Plan to pay for the laboratory testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not a covered benefit. 
 
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 81238 is not supported in the medical record. Specifically, the documentation shows 
that the enrollee had molecular pharmacogenetic testing that were billed with multiple codes. When a 
laboratory assays two or more genes in an enrollee in parallel, those two or more genes will be considered part 
of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the panel. 
This one code was submitted on its own on a separate claim form but was performed at the same time and same 
date of service as the other codes. This means this code is not separately payable. Based on this information, 
we decided that Medicare rules for coverage of the laboratory testing have not been met. Therefore, we decided 
that the Plan does not have to pay for the laboratory testing coded 81238 provided on April 29, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the Intracept procedure provided on April 13, 2021. 
 
You asked the Plan to pay for the services provided. You say that the procedure has improved your chronic 
condition. The Plan denied your request. The Plan says that unproven procedures are not covered by Medicare. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the services provided by a contract provider. The file does not show that the Plan 
provided notice that the services provided would not be covered. Under Medicare rules, this means the services 
provided is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the Intracept 
procedure provided on April 13, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit rendered on February 7, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. The file shows that the 
provider billed procedure code 99212 (office visit). Therefore, we decided that the Plan does not have to pay 
for the office visit rendered on February 7, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth services rendered on August 30, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
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 H2017 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code H2017 is not valid for Medicare purposes. 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 pay for the 
telehealth services rendered on August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (99204) provided on 
July 20, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be 
covered as you disagree with the charges and the services were provided in-network. The Plan denied your 
request. The Plan says the cost-sharing applied correctly based on the services provided. 
 
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 $55 
copayment for Physician/Practitioner services, including doctors office visits, specifically out-of-network 
specialist visits.  
 
 
  You have been asked to pay a $55 copayment for the specialist office visit. The record indicates the specialist 
provider is not in-network with the Plan. 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 a specialist 
office visit (99204) provided on July 20, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a colonoscopy (45378). 
 
You asked the Plan to pre-approve a colonoscopy. You say that the requested service is medically necessary. 
The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that colonoscopies are considered medically necessary for 
specific 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 a colonoscopy. Our reviewer says that 
the criteria for coverage have not been met for the requested colonoscopy. Our physician reviewer found the 
provided documentation does not indicate that the enrollee has signs of a gastrointestinal (GI) bleed. The 
documentation does not indicate that the enrollee is due for a repeat colonoscopy. The documentation does not 
indicate a chronic GI illness which needs monitoring with colonoscopy. Therefore, the reviewer found that the 
coverage criteria for the requested colonoscopy 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 a colonoscopy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a colonoscopy (45378).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a Stellate Ganglion injection. 
 
You asked the Plan to pre-approve the requested services. You say that you are still having sensitivity to loud 
noises. The Plan denied your request. The Plan says that this is considered investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 requested services. Our physician 
reviewer found that you have post-herpetic neuralgia of the eyelid and forehead. Trials of Prednisone and 
Hydrocodone have not helped. The request is for a Stellate ganglion block, not neural therapy. The 
documentation does support that it is medically reasonable and necessary to perform a stellate ganglion block 
in this case. 
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve a Stellate Ganglion injection.  
 
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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 your functional status was consistent with a deconditioned state following an acute 
hospital stay. You did not have more than usual post-acute rehabilitation needs. You did not require intensive or complex rehabilitation services. You did not require frequent physiatry oversight. You had no medical needs 
that were a barrier to rehabilitation and warranted an acute hospital stay. Your rehabilitation needs could 
reasonably be met without admission to an acute inpatient 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.