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

 
We decided that the Plan does not have to pay for the infrared therapy (97026) and office visit (99203) 
provided on June 1, 2021. 
 
You asked the Plan to pay for the infrared therapy and office visit. You say that you would like these claims 
reprocessed and approved for payment. The Plan denied your request. The Plan says these services are not 
covered when performed by a chiropractor. 
 
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. Therefore, we decided that 
the Plan does not have to pay for the infrared therapy (97026) and office visit (99203) provided on June 1, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost sharing for the arthrocentesis procedure, the 
fluoroscopic guidance, and the methylprednisone acetate injection you received from a specialist on March 24, 
2021. 
 
You asked the Plan to reduce the cost sharing for the arthrocentesis procedure, the fluoroscopic guidance, and 
the methylprednisone acetate injection. You say that all of these services should be covered under your $40 
copayment for specialist services. The Plan denied your request. The Plan says you were charged these cost 
sharing amounts correctly.  The Plan says that for the fluoroscopic guidance service, the allowed amount for 
this service ($49.27) is less than your copayment obligation, so you are responsible for the full allowed 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 $50 
copayment for diagnostic radiology services.  
 
You have been asked to pay a $50 copayment for the fluoroscopic guidance, 20% coinsurance for the 
methylprednisone acetate injection, and a $40 copayment for the arthrocentesis procedure. The fluoroscopic 
guidance is a diagnostic radiology service. The methylprednisone acetate injection is a Medicare Part B drug. 
Your Evidence of Coverage explicitly states that if you have a procedure in a specialist?s office, there will be 
separate cost sharing for these additional services. 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 reduce the cost sharing for 
the arthrocentesis procedure, the fluoroscopic guidance, and the methylprednisone acetate injection you 
received from a specialist on March 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on January 24, 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 procedure codes 35141 and 37224 are not supported. 
 
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 35141 is direct repair of aneurysm, pseudoaneurysm, or 
excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and 
associated occlusive disease, common femoral artery (profunda femoris, superficial femoral). The definition of 
code 37224 is revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; 
with transluminal angioplasty. 
 We find that CPT codes 35141 and 37224 are not supported in the medical record. Specifically, there is no 
documentation of direct repair of an aneurysm, pseudoaneurysm, or excision and graft insertion to support code 
35141. There is no documentation of endovascular revascularization to support code 37224. 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 surgical services rendered on January 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (CPT code 22899, C9752 and 
C9753), for the enrollee. 
 
You asked the Plan to pre-approve the intracept procedure. You say that this procedure fills a treatment gap for 
those patients that do not receive adequate relief from traditional conservative methods and do not have 
instability to indicate that fusion is the appropriate treatment. You state the enrollee has tried and failed 
conservative treatment without relief. The Plan denied your request. The Plan says unproven and not medically 
necessary procedures are not covered by Medicare due to insufficient evidence of efficacy. 
 
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 for back pain. 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 (CPT code 22899, C9752 and C9753), for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided on June 18, 2020. 
 
You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
member?s terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness  
until the first day of the month following the month in which hospice was revoked or discharged.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on June 9, 2020. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on June 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of country services received from May 4, 2021, to May 
13, 2021. 
 
You asked the Plan to pay for the services. You say that you felt forced to go to Mexico for treatment. The Plan 
denied your request. The Plan says this request cannot be approved.  
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
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 services. Our reviewer says that the 
services at issue in this case were not medically reasonable. Our physician reviewer found the review has 
determined that the enrollee could have foreseen requiring the services prior to leaving his service area. It 
would have been it be (or have been) medically reasonable to delay the services until when the enrollee 
returned to his service area. In this case, you went on your own to Mexico for an evaluation. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for out of country services received from May 4, 2021, to May 13, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services provided by an occupational therapist on April 28, 2021.
You asked the Plan to pay for the occupational therapy services. You say that the medical records required to reprocess the denied claim are attached. The Plan denied your request. The Plan says the records do not support the code billed.
The Plan must follow Medicare rules. Medicare rules say that services of an occupational therapist billed as services incident to a physician/non-physician practitioner's service must meet all incident requirements. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the occupational therapy services have not been met. Specifically, the billing provider is a physician assistant. As such, occupational therapy services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for occupational therapy services provided by an occupational therapist on April 28, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on May 29, 2021. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you did not require 
the ambulance and should not have to pay the full amount. The Plan denied your request. The Plan says the 
Medicare ambulance benefit is a transportation benefit and without transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 29, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
(A0998) provided on May 29, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation with medical services 
coded 90792 provided on May 12, 2021. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation with medical services. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not 
payable as 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, the CPT Code Manual definition of code 90792 is psychiatric diagnostic evaluation with medical 
services. 
 
 We find that CPT code 90792 is not supported in the medical record. Specifically, this code was billed with a 
primary diagnosis of F05 (Delirium due to known physiological condition). This code is a secondary only 
diagnosis and therefore, cannot be used as the primary, first-listed, or principal diagnosis for any procedure or 
service. Based on this information, we decided that Medicare rules for coverage of the psychiatric diagnostic 
evaluation with medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for the psychiatric diagnostic evaluation with medical services coded 90792 provided on May 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided the Plan does not have to pay for ambulance transport provided to the enrollee on June 25, 2021. 
 
You asked the Plan to pay for this transport. You say that this claim should be paid. The Plan denied your 
request. The Plan says this the claim denied because it did not include the appropriate primary or first listed 
diagnosis which is based on the Medicare billing guidelines. The claim indicates the provider reported  
diagnosis B95.62 as primary/first listed. The Medicare guidelines state for bacterial and viral  
infectious agents (B95-B97), these categories are provided as a supplementary or additional code to  
identify the infectious agents (s) in diseases classified elsewhere. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case the claim lacks an appropriate primary 
diagnosis code in the first position.  
 Medicare rules for coverage of this transport have not been met. Therefore, we decided that the Plan does not 
have to pay for ambulance transport provided to the enrollee on June 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urovysion cytopathology services provided on May 19, 
2021, billed with code 81121. 
 
You asked the Plan to pay for the Urovysion testing. You say that this was a necessary test to monitor the 
enrollee's condition. The Plan denied your request. The Plan says this was done for screening purposes. Bladder 
cancer tumor markers performed by any technology immunoassay, molecular or FISH testing, are not covered 
for screening of all patients with hematuria. 
 
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 Urovysion testing. Our reviewer says 
that the testing services provided are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Urovysion is considered experimental/investigational as a screening test for 
urothelial cancer. Cystoscopy, ureteroscopy, possible biopsy and upper tract imaging will still be necessary 
regardless of the results of Urovysion testing. Urovysion testing is not medically necessary to evaluate patients 
with asymptomatic microscopic hematuria.     
 
Urinary biomarker tests such as Urovysion give significant false-negative results in patients with urothelial 
cancer and are subject to false-positive results in others. Accuracy is poor for low-stage and low-grade tumors. 
To date, there are multiple urine markers that have improved sensitivity over cytology but there is lack of 
validation of clinical utility. Some of the recently developed markers aim to change the paradigm of urothelial 
diagnosis and follow-up by replacing or reducing the need of invasive investigations. Further prospective 
validations are needed to confirm these findings.  
 
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 Urovysion testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the Urovysion cytopathology services provided on May 19, 2021, billed with code 
81121.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transports provided on June 
1, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transports. You say that you were discharged 
too soon and had to go back to the hospital by ambulance. You say you should not bear the responsibility of the 
hospital's mistake. 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 $350 
copayment for per ambulance trip.  
 
You had two ambulance trips on June 1, 2021. You have been asked to pay a $350 copayment for one of them. For the second one, you have been asked to pay $325.40, which is less than the $350 copayment. Your total for 
both trips is $675.40 ($350 + $325.40 = $675.40). Ambulance transports fall within the Ambulance 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 the copayment for the ambulance transports 
provided on June 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve adjacent tissue transfer or rearrangement (CPT code(s): 
14041, 14302, and 14301) to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that you are requesting review of 
denial of services. The Plan denied your request. The Plan says there are in-network providers that can provide 
the services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
adjacent tissue transfer or rearrangement (CPT code(s): 14041, 14302, and 14301) to be provided by an out-of-
network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies haven't proven that the device is helpful for treatment of the enrollee's 
health problem. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this device 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest (71250) 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a CT scan of the chest to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a computed tomography (CT) scan of the chest (71250) to be provided by an out-of-network (OON) provider.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
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 the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a 
reasonable expectation that the enrollee 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 inpatient rehabilitation facility (IRF) admission and services.