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

 
We decided that the Plan has to provide reimbursement in full for the medical services provided on January 10, 
2023.  
 
You asked the Plan to provide reimbursement in full for the medical services. You say that you paid $602 up 
front and feel it is not correct to be reimbursed only the Medicare-allowed amount.  The Plan denied your 
request. The Plan says that payment can only be made for the Medicare-allowed amount. You are responsible 
for amounts beyond this. 
 
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 provided with the medical services by a contract provider. A network provider is not allowed to 
accept payment above the Medicare allowable, and the Plan must ensure this. In this case, the Plan did not 
indicate that the provider would be required to refund you the excess payment. Under Medicare rules, this 
means the Plan must reimburse you in order to hold you harmless for these excess charges. Therefore, we 
decided that the Plan has to provide reimbursement in full for the medical services provided on January 10, 
2023.   
 
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 pre-approve RFA of the genicular nerve. 
 
You asked the Plan to pre-approve the RFA. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the request 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 the RFA. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that genicular nerve blocks and genicular nerve ablation are considered 
experimental/investigational and are not medically necessary for the treatment of chronic knee pain. 
 
 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 RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve RFA of the genicular nerve.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the physical therapy visit (97162, 97140) 
provided on July 31, 2023. 
 
You asked the Plan to waive the copayment for the physical therapy visit (97162, 97140). You say that you do 
not agree with the copayment for the service you received. 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 services performed at a 
hospital outpatient facility are subject to the outpatient hospital copayment. It also says that enrollees must pay 
a $150 copay for Medicare-covered observation services. 
 
You have been asked to pay a $144.14, which is less than the standard $155 copayment for physical therapy. 
This item/service falls within the outpatient rehabilitation services and outpatient hospital observation 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 physical therapy visit (97162, 97140) 
provided on July 31, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two units of 64420 and two units of procedure code 76942 
rendered on July 6, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the units were not reported properly. 
 
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 the denied codes is: 
 
CPT 64420: 
 
Injection(s), anesthetic agent(s) and/or steroid; intercostal nerve, single level 
 
CPT 76942: 
 
Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging 
supervision and interpretation 
 
In this case, the MUE for CPT code 64420 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. 
 
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 additional units of CPT 76942. Our reviewer says that the services at 
issue in this case were not supported by the medical records. Our reviewer found that two units of 76942 are 
not supported. The record supports 1 unit of 76942. 
 
We looked at this coder'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 two units of 64420 and two units of procedure code 76942 rendered on July 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) and shaving of epidural lesion 
(11300) provided on May 23, 2023. 
 
You asked the Plan to pay for the office visit (99203) and shaving of epidural lesion (11300). You say that the 
services should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care 
is not covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit (99203) 
and shaving of epidural lesion (11300) provided on May 23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve open implantation of hypoglossal nerve neurostimulator 
array, pulse generator, and distal respiratory sensor electrode or electrode array (64582), generator, 
neurostimulator (implantable), non-rechargeable (C1767), patient programmer, neurostimulator (C1787). 
 
You asked the Plan to pre-approve open implantation of hypoglossal nerve neurostimulator array, pulse 
generator, and distal respiratory sensor electrode or electrode array, generator, neurostimulator (implantable), 
non-rechargeable, patient programmer, neurostimulator. You say that this is medically necessary. The Plan 
denied your request. The Plan says the request is not medically necessary because the records show the enrollee 
has a PSG showing 76.8 AHI/hour that is not within 15-65 events/hour. 
 
The Plan follows Medicare rules. Medicare rules say that hypoglossal nerve stimulation can be covered when 
specific criteria are met. 
 
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 open implantation of hypoglossal nerve 
neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array, generator, 
neurostimulator (implantable), non-rechargeable, patient programmer, neurostimulator. Our reviewer says that 
there is no documentation that the hypoglossal nerve neurostimulator at issue in this case meets all Medicare 
criteria for medically reasonable and necessary and safe and effective for the patient. Our physician reviewer 
found the provided records in this case do not document a polysomnography demonstrating an apnea-hypopnea 
index (AHI) of 15 to 65 events per hour within 24 months of the initial consultation for the device implantation 
as required. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of open implantation of hypoglossal nerve neurostimulator array, pulse generator, 
and distal respiratory sensor electrode or electrode array, generator, neurostimulator (implantable), non-
rechargeable, patient programmer, neurostimulator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve open implantation of hypoglossal nerve neurostimulator array, pulse generator, and 
distal respiratory sensor electrode or electrode array (64582), generator, neurostimulator (implantable), non-
rechargeable (C1767), patient programmer, neurostimulator (C1787).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the charges for the emergency room services and the related 
self-administered medications provided from July 16, 2023, through July 18, 2023.  
 
You asked the Plan to waive the charges for the emergency room services and medications. You say that you 
were in need of medically necessary inpatient care due to your compression fracture and severe pain. 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 you must pay a $110 
copayment for emergency room services. The rules also say that most self-administered drugs are not covered 
by Medicare Part B when provided in the outpatient setting.  
 
Your appeal letter indicates that you were under the impression that this was an inpatient stay and that coverage 
was denied. Please note that you were treated under outpatient observation as you were not formally admitted 
as an inpatient. 
 
You have been asked to pay a $110 copayment for the emergency room services. This falls within the 
emergency room 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. In addition, during your stay you were provided with medications of a type that are usually 
self-administered by those who take them. This means that they do not fall into a covered Medicare Part B 
benefit category. As such, you are being correctly asked to pay $313.28 for these medications. Therefore, we 
decided that the Plan does not have to waive the charges for the emergency room services and the related self-
administered medications provided from July 16, 2023, through July 18, 2023.   
 
Benefits for medications denied under Part B 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 pay for continuous glucose monitor (CGM) supplies provided on 
June 24, 2023. 
 
You asked the Plan to pay for CGM supplies. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. The delivery receipt does not include specification of the items delivered to the enrollee to support the code billed on this claim. The record shows that the Plan made 
several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan 
does not have to pay for continuous glucose monitor (CGM) supplies provided on June 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown (D6751). 
 
You asked the Plan to pre-approve D6751. You say that this dental work is medically necessary. The Plan 
denied your request. The Plan says the requested dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
retainer crown (D6751).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hymovis injection. 
 You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the enrollee has not tried and failed preferred medications. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 medication. Our reviewer says that 
the requested medication does not meet the requirements for step therapy guidelines. Our physician reviewer 
found the requested medication is a new start. The provided records do not indicate that the enrollee has tried 
and failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a 
contraindication to, or would have an adverse effect from the plan's preferred step one alternative. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a hymovis injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair and bathtub rail.  
 
You asked the Plan to pre-approve a shower chair. You say that you would like reconsideration because the 
requested shower chair and bathtub rail are medically necessary. The Plan denied your request. The Plan says 
this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair and bathtub rail.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 20, 2022, billed with 
procedure codes 97610-GP-59, 29581-GP-50-XS, 97112-GP-59, 97110-GP, 97116-GP-59, 97028-GP-59. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 codes 97610-GP-59, 29581-GP-50-XS, 97112-GP-59, 97110-
GP, 97116-GP-59, 97028-GP-59 is application of multi-layer compression system; leg (below knee), including 
ankle and foot, application of a modality to 1 or more areas; ultraviolet, therapeutic procedure, 1 or more areas, 
each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility, 
therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities, therapeutic 
procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing), and low frequency, non-
contact, non-thermal ultrasound, including topical application(s), when performed, wound assessment, and 
instruction(s) for ongoing care, per day. 
 
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 the practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that the services in question are not 
supported. The documentation states that the services were performed as home physical therapy services. 
Medicare requires a different code for these services. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on April 20, 2022, billed with procedure codes 
97610-GP-59, 29581-GP-50-XS, 97112-GP-59, 97110-GP, 97116-GP-59, 97028-GP-59.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and scanning computerized ophthalmic 
diagnostic imaging provided on June 16, 2023. 
 
You asked the Plan to pay for an office visit and scanning computerized ophthalmic diagnostic imaging. You 
say that the services should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit and 
scanning computerized ophthalmic diagnostic imaging provided on June 16, 2023.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cardiac rehabilitation services provided on 
July 03, 2023, to July 31, 2023. 
 
You asked the Plan to waive the copayment for cardiac rehabilitation services. You say that you disagree with 
the 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 you must pay a $30 
copayment for cardiac rehabilitation services. 
 
You have been asked to pay a $30 copayment for cardiac rehabilitation services. This item/service falls within 
the cardiac rehabilitation services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total amount you are being asked to pay $330 ($30 x 11 visits = $330). 
Therefore, we decided that the Plan does not have to waive the copayment for cardiac rehabilitation services 
provided on July 03, 2023, to July 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #7. 
 
You asked the Plan to pre-approve the dental services. You say that you need this dental crown. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service November 8, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth #7.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methotrexate. 
 
You asked the Plan to pre-approve the medication. You say that the records support the medication needed. 
The Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
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 Methotrexate. Benefits for the medication 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on January 17, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says per Local Coverage 
Article A58726, this type of testing must be billed with a single unit of service of a single code. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab panel provided on January 17, 2023.