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

 
We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging provided 
by an in-network on July 14, 2023, and the transthoracic echocardiogram (TTE) provided by an in-network 
provider on July 27, 2023.  
 
You asked the Plan to waive the copayment for the myocardial perfusion imaging and the TTE. You say that 
you feel that the copayment is unfair and should be covered. 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 $200 
copayment per day for other in-network Medicare-covered diagnostic radiology services that are not 
ultrasounds, and a $30 copayment per day for in-network Medicare-covered outpatient diagnostic tests. 
 
You have been asked to pay a $200 copayment for the myocardial perfusion imaging. You have also been 
asked to pay a $30 copayment for the TTE. These items/services fall within the outpatient diagnostic tests and 
therapeutic services and 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 copayment for 
the myocardial perfusion imaging provided by an in-network on July 14, 2023, and the transthoracic 
echocardiogram (TTE) provided by an in-network provider on July 27, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve the additional trips. You say that you have cancer along with additional 
other chronic conditions and need to receive the additional rides because it is a medically necessary. You also 
say that you did not receive the information pertaining to limited rides. The Plan denied your request. The Plan 
says the records show you have reached your plans maximum allowance of 24 trips.  
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 a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve the 
additional transportation trips for your medical appointments. Based on this information, we decided that you 
have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that 
the Plan does not have to pre-approve additional routine transportation trips (A0100).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the tetanus and diphtheria toxoids adsorbed (Td) 
(90417), and administration (90471) provided on May 27, 2023. 
 
You asked the Plan to reimburse you for the immunization services. You say that you incurred an injury. You 
say that you had blood spurting from your leg. You also say that during treatment it was determined you 
needed a tetanus shot since your last shot was in 2016. The Plan denied your request. The Plan says these 
services are not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the immunization 
services. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the immunization 
services. Therefore, we decided that the Plan does not have to reimburse you for the tetanus and diphtheria 
toxoids adsorbed (Td) (90417), and administration (90471) provided on May 27, 2023.  
 Benefits for the immunization services 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an in-home physician visit. 
 
You asked the Plan to pre-approve an in-home visit. You say that the enrollee does not have the stamina to go 
to appointments in the community. The Plan denied your request. The Plan says that medical necessity criteria 
for the in-home physician visit has not been met. 
 
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 an in-home visit. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the provided documentation did not suggest the enrollee was unable or would be unable to 
be seen in the office. It was not clear that the enrollee would not be able to be seen sooner via a different in-
network physician who could treat the enrollee in a timelier fashion, which appears most appropriate in this 
situation rather than in-home physician visits. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an in-home visit have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an in-home physician visit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laser treatment on birth mark that is growing. 
 
You asked the Plan to pre-approve laser treatment. You say that you are appealing the denial. The Plan denied 
your request. The Plan says this 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 laser treatment. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided medical records and review of the current peer-reviewed medical literature do not 
document that use of laser treatment for a port wine birthmark with no reported bleeding or complication meets 
Medicare criteria for reasonable and necessary. The peer-reviewed medical literature does not support 
prophylactic laser treatment in the Medicare population. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of laser treatment have not been met. Therefore, we decided that the Plan does not 
have to pre-approve laser treatment on birth mark that is growing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99387) provided on July 31, 2023. 
 
You asked the Plan to pay for the outpatient service. You say that your previous primary care physician (PCP) 
retired. You say that you needed to establish care with a new provider. You also say that you did not know that you needed to tell them that you needed a wellness visit instead. The Plan denied your request. The Plan says 
the benefit for this service has been exhausted. 
 
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 one physical exam is covered 
calendar year. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient service have not been met. Specifically, the file supports that the Plan has paid for 
this service earlier in the year. Therefore, we decided that the Plan does not have to pay for the office visit 
(99387) provided on July 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36248 and 75774 billed for date of service 
March 28, 2023.  
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 36248 is 6 and the MUE for CPT code 75774 is 7. The MAI value for this 
code is 3. You billed 11 units for code 36248 and 15 units for code 75774, exceeding the MUE. The medical 
records do not include rationale as to why additional units were needed to treat the enrollee in this case. Based 
on this information, we decided that Medicare rules for coverage of procedure code 36248 and 75774 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 36248 and 75774 billed 
for date of service March 28, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Invega Sustenna. 
 
You asked the Plan to pre-approve the drug. You say that since being on this drug the enrollee has been more 
stable and needs to continue this regimen to stay out of inpatient treatment. The Plan denied your request. The 
Plan says that self-administered drugs do not fall under Medicare Part B coverage. 
 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 Invega Sustenna.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the polycarbonate lens and the vision item provided on June 15, 2023. 
 
You asked the Plan to pay for the polycarbonate lens and the vision item. You say that you had to purchase a 
new pair of glasses because the first pair was uncomfortable. The Plan denied your request. The Plan says that 
the benefit has been exhausted. 
 
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 Plan did not submit documentation showing that the Plan had previously 
paid for eyewear. This means we are unable to determine if the benefit has been exhausted. Therefore, we 
decided that the Plan has to pay for the polycarbonate lens and the vision item provided on June 15, 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 pay for procedure code 99458 billed for date of service June 30, 
2023.  
 You asked the Plan to pay for procedure code 99458. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 99458 is 3. The MAI value for this code is 3. You billed 5 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99458 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99458 billed for date of service June 30, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a colonoscopy (45378) to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the colonoscopy. You say that the patient was recommended to have a 
colonoscopy done every five years due to personal history of colon polyps. The Plan denied your request. The 
Plan says the requested service is not urgent/emergent, and there is no network deficiency. 
 
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 colonoscopy (45378) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G orthosis (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthosis. You say that the device is medically necessary. The Plan 
denied your request. The Plan says there is insufficient evidence in the literature that this device will increase 
participation in bimanual activities. 
 
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 a MyoPro orthosis. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the MyoPro orthosis is not known to be effective, based on scientific evidence, 
professional standards, and expert opinion, in improving health outcomes. The MyoPro is not the standard of 
care for this enrollee's condition or in widespread use for this enrollee's condition based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes 
for this enrollee. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 
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 MyoPro orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro Motion G orthosis (L8702).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan.  
 
You asked the Plan to pre-approve the PET scan. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 pre-approve the PET scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found that the enrollee was only noted to have an 
unspecified form of dementia. There was no indication or a diagnosis of either, let alone both, AD and FTD. 
Given that the baseline requirement for coverage was not met, this service would not be eligible for coverage. 
 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve TRELEGY AER. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary. 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 TRELEGY AER.   
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve copanlisib(J9057) and Imfinzi (J9173). 
 
You asked the Plan to pre-approve the drugs. The Plan denied your request. The Plan says that the requested 
drug would be deemed a routine cost covered by the Medicare Administrative Contractor (MAC). 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve the drugs as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve copanlisib(J9057) and Imfinzi (J9173).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve side guards for a wheelchair. 
 
You asked the Plan to pre-approve side guards. You say that you are appealing this denial. The Plan denied 
your request. The Plan says this component is not primarily medical in nature and is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve side guards for a wheelchair.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CTA scan of the chest. 
 
You asked the Plan to pre-approve a CTA scan of the chest. The Plan denied your request. The Plan says a 
CTA scan of the chest is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 a CTA scan of the chest. Our reviewer 
says that a CTA scan of the chest is not medically necessary. Our physician reviewer found that the enrollee 
has no evidence of coronary disease on the past cardiac imaging. Therefore, at this time a chest CTA would not 
be considered medically reasonable and necessary in the enrollee's clinical management. 
 
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 CTA scan of the chest have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CTA scan of the chest.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99221-25 billed for date of service January 
26, 2023. 
 You asked the Plan to pay for procedure code 99221-25. You say that  this service was necessary and 
separate from the procedure provided on the same date. The Plan denied your request. The Plan says neither the 
CPT code nor the modifier can be verified in this case; therefore, this service cannot be paid. 
 
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 99221-25 is initial hospital inpatient or observation care, 
per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and straightforward or low level medical decision making. When using total time on the date of 
the encounter for code selection, 40 minutes must be met or exceeded. 
 
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 99221-25. Our reviewer says that code 99221 
is not supported in this case. Our reviewer found the records provided do not include an evaluation and 
management procedure report, and therefore neither code 99221 or the appended modifier can be verified. 
 
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 99221-25 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99221-25 billed for date of service January 26, 2023.