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

 
We decided that the Plan does not have to pre-approve insertion of an implantable loop recorder (ILR). 
 You asked the Plan to pre-approve insertion of an ILR. 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 follows Medicare rules. Medicare rules say that cardiac event monitors are 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 insertion of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found based on current guidelines and the 
documentation provided, there is insufficient clinical evidence to support the medical appropriateness and 
necessity of replacing your old ILR with a new ILR. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of an ILR have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of an implantable loop recorder (ILR).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the BRCA1, BRCA2 (breast cancer 1 and 2) gene analysis 
(81162) provided February 7, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that the enrollee's physician ordered the Invitae 
Hereditary Cancer test due to the enrollee being personally affected by breast and ovarian cancer. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The records show that the enrollee does not have a cancer diagnosis. 
Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the BRCA1, BRCA2 (breast cancer 1 and 2) 
gene analysis (81162) provided February 7, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service February 
18, 2023. 
 You asked the Plan to pay for procedure code 70450-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 70450-26 is bundled into 
payment for code 70496-26. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 
70450-26 is a column II code to column I code 70496-26. This claim has not been billed with an appropriate 
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service 
February 18, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency transportation. 
 
You asked the Plan to pre-approve non-emergency transportation. You say that you have amyloidosis and take 
a pill each day for it. You also say that you have kidney disease, need help, and you go to all of your doctors 
each week. The Plan denied your request. The Plan says the requested service does not meet the criteria for 
medical necessity or appropriateness as outlined in the benefit booklet.  
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when you are diagnosed with both Diabetes and CHF. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the information 
provided shows that you are not being treated for both diabetes and congestive heart failure. Therefore, we 
decided that the Plan does not have to pre-approve non-emergency transportation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure) (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the doctors have tried everything to 
help you with your back pain. You say that the doctor feels this procedure will help you pain and get you out of 
your wheelchair. You also say that you are unable to walk more than 20 steps without excruciating pain. The 
Plan denied your request. The Plan says the requested procedure 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 Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation does not support modic changes without facet degenerative joint disease or foraminal stenosis. The reviewer also found that the documentation does not 
clearly indicate the cause of your back pain. Therefore, the reviewer found that the requested Intracept 
procedure is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept procedure) 
(64628, 64629).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the electroencephalogram (EEG) during nonintracranial surgery 
(95955) provided on November 8, 2022. 
 
You asked the Plan to pay for the EEG. You say that the service should be paid. The Plan denied your request. 
The Plan says that the service was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The file indicates that medical records were provided to the Plan. The Plan did 
not submit any medical records to support their denial. Therefore, we decided that the Plan has to pay for the 
electroencephalogram (EEG) during nonintracranial surgery (95955) provided on November 8, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hernia repair provided on October 21, 2022. 
 
You asked the Plan to pay for the hernia repair. You say that you are requesting reconsideration of the denied 
claim. 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 hernia repair 
provided on October 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. You say that you have been experiencing back pain and 
stiffness. The Plan denied your request. The Plan says epidural steroid injection 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 injection. Our reviewer says that 
that you do not meet the coverage criteria. Our physician reviewer found that you have a history of chronic low 
back pain due to osteoarthritis and have been treated with medication including opiates and epidural steroid 
injections. However, the reports show that your last epidural steroid injection on June 7, 2023, has made your 
back pain worse. Therefore, you do not meet the LCD coverage criteria. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 9, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that the enrollee was unaware that the provider was out-
of-network. The Plan denied your request. The Plan says enrollees must receive their care from a network 
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 item/service 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 this item/service. Therefore, 
we decided that the Plan does not have to pay for the office visit provided on February 9, 2023, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electroencephalogram (EEG); recording in coma or sleep 
only rendered on July 1, 2022. 
 
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 records do not support the services 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 95822 is Electroencephalogram (EEG); recording in 
coma or sleep only. 
 
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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that in this case, the enrollee 
underwent lumbar spine surgery. Intraoperative neuromonitoring services were provided. However, the 
services provided did not meet the minimum technical standards established by the American Clinical 
Neurophysiology Society (ACNS) for performance of an electroencephalogram (EEG). Rather, an insufficient 
number of channels were recorded in order for the requirements of the code be met. The EEG done in this case 
was a simple two channel EEG which in and of itself is not sufficient for the diagnosis or management of the 
enrollee's condition. 
 
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 electroencephalogram (EEG); recording in coma or sleep only rendered on July 1, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
November 09, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you have not paid 
for emergency transportation in the past. 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 $250 
copayment for ambulance services. 
 
You have been asked to pay a $250 copayment for the ambulance transportation. This item/service falls 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 transportation provided on November 09, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facet joint injections. 
 You asked the Plan to pre-approve the injections. You say that you have polio and need the injections for your 
current medical condition. The Plan denied your request. The Plan says the facet joint injections are 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 injections. Our reviewer says that 
the enrollee does not meet the coverage criteria. Our physician reviewer found that you have radiculopathy. 
However, there is no documentation of at least 3 months of conservative care such as physical therapy, a home 
exercise strengthening or conditioning program. Therefore, you do not meet the LCD coverage criteria. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the facet joint injections.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (U0005) provided on November 2, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim was not billed with a valid 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 the lab services 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 lab services (U0005) provided on November 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 85060 billed for date of service January 
23, 2023. 
 You asked the Plan to pay for procedure code(s) 85060. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this code is included in the facility payment and is not separately 
payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 85060. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 85060. Based on this information, 
we decided that Medicare rules for coverage of procedure code 85060 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 85060 billed for date of service January 23, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth visit provided on March 09, 2023. 
 
You asked the Plan to pay for telehealth visit. You say that you were the only available provider to render 
services via telehealth. 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 telehealth visit provided 
on March 09, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
October 27, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you cannot afford 
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 $265 
copayment for ambulance services.  
You have been asked to pay a $265 copayment for the ambulance transportation. This item/service falls 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. However, since the allowed amount is less than the standard copayment, you only owe 
$228.42. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance 
transportation provided on October 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network shoulder injection provided 
on October 11, 2022. 
 
You asked the Plan to waive the copayment for an in-network shoulder injection. You say that you want this 
reviewed as it seems excessive. 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 $35 
copayment for services obtained from a specialist, and a $280 copayment for Medicare-covered surgery or 
other services provided to you at an outpatient hospital, including but not limited to hospital or other facility 
charges and physician or surgical charges.  
 
You have been asked to pay the allowed amount of $275.54 which is less than the $280 copayment for an 
outpatient procedure. There is also a $35 copayment for the specialist ($275.54 + $35 = $310.54). 
 
You have been asked to pay a total $310.54 copayment for services obtained from a 
specialist, and a Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges for an in-network shoulder 
injection. This item/service falls within the services obtained from a specialist, and a Medicare-covered surgery 
or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility 
charges and physician or surgical charges 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 an in-network shoulder injection provided on October 11, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on October 18, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this provider type is not eligible in the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Mental Health Counselor is not eligible to 
participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Mental Health Counselor. 
Medicare says that a Mental Health Counselor is not eligible to participate in the Medicare program. Therefore, 
we decided that the Plan does not have to pay for psychotherapy provided on October 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit for evaluation provided on February 24, 2023. 
 
You asked the Plan to pay for home visit for evaluation. You say that you say the assisted living facility is 
responsible to obtain prior authorization for all of their patients. 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 home visit for 
evaluation provided on February 24, 2023.