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

 
We decided that the Plan does not have to pay for each psychotherapy service provided from May 3, 2023, to 
May 23, 2023, by an OON provider.  
 You asked the Plan to pay for each psychotherapy service. You say that the provider is in-network with 
Medicare. The Plan denied your request. The Plan says the provider is out-of-network with the Plan, and the 
services were not authorized. 
 
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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for each psychotherapy service provided from May 3, 
2023, to May 23, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit, and debridement of nails provided on June 07, 
2023. 
 
You asked the Plan to pay for a home visit, and debridement of nails. You say that these services were 
medically necessary. 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 a home visit, and 
debridement of nails provided on June 07, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ambulatory infusion pump (E0781) and supplies (A4221, 
A4222). 
 
You asked the Plan to pay for an ambulatory infusion pump and supplies. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an external infusion pump may be covered if an 
infusion pump is necessary to safely administer the drug.  
 
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 an ambulatory infusion pump and supplies. 
Our reviewer says that the item is not medically necessary. Our physician reviewer found the prescribed 
antibiotics can be safely administered without an infusion pump. 
 
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 ambulatory infusion pump and supplies have not been met. Therefore, we 
decided that the Plan does not have to pay for an ambulatory infusion pump (E0781) and supplies (A4221, 
A4222).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neupogen. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
Plan's required drugs, Zarxio and Nivestym. The records do not show that the required drugs would be 
contraindicated or less effective; therefore, Neupogen is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Neupogen.
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 enrollee requires and will benefit from IRF 
services in order to increase their independence and return to their prior level of function. You would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the requested IRF 
admission is not medically necessary.  
 
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 complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs.  The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical therapy  and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that this 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service May 31, 
2023.   
You asked the Plan to pay for procedure code 88341. You say that you disagree with the 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 88341 is 13. The MAI value for this code is 3. You billed 14 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 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service May 31, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0453 provided on May 23, 2023. 
 
You asked the Plan to pay for procedure code G0453. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the records do not support the service 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 G0453 is Continuous intraoperative neurophysiology monitoring, from outside the operating room 
(remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition 
to primary procedure). 
 
We find that CPT code G0453 is supported in the medical record. Specifically, the record shows that 
intraoperative neurophysiology monitoring was started at 08:22 and stopped at 12:45, totaling 4 hours and 23 
minutes, which would be 15 minutes per each unit billed, totaling 18 units billed correctly. Based on this 
information, we decided that Medicare rules for coverage of procedure code G0453 have been met. Therefore, 
we decided that the Plan has to pay for procedure code G0453 provided on May 23, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the heat pad (E0217) provided from February 10, 2023, to 
March 2, 2023. 
 
You asked the Plan to pay for the heat pad. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that if code E0215 or E0217 is provided it will be 
denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. The requested heat pad (E0217) is not medically reasonable and 
necessary, and therefore is not covered. Based on this information, we decided that Medicare rules for coverage 
of the heat pad have not been met. Therefore, we decided that the Plan does not have to pay for the heat pad 
(E0217) provided from February 10, 2023, to March 2, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychotherapy services with an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve the OON psychotherapy services. You say that you want to see the OON 
provider because of his expertise in a treatment method called Emotional Freedom Technique (ETF) to treat 
your medical conditions.  The Plan denied your request. The Plan says you can receive medically necessary and 
adequate care from a network provider. The Plan says that the network provider you had recently starting 
receiving care from is using the Cognitive Behavioral Therapy (CBT) method, which is the highest form of 
evidence-based treatment available.  
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for 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 pre-approve the OON psychotherapy services. Our 
reviewer says that the criteria for coverage of OON care have not been met. Our physician reviewer found you 
can receive care from a therapist who is in network and who has regional expertise in the treatment of anxiety 
and sleep issues. The records provided support that you can be treated by an in-network provider for your 
medical conditions. The Plan has supported that the network providers being offered are credentialed and 
clinically maintained individuals who meet the Standards of Care for treatment of your conditions. 
 
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 OON psychotherapy services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve psychotherapy services with an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each radiation therapy service provided on 
May 24, 2023, to June 07, 2023. 
 
You asked the Plan to waive the copayment for each radiation therapy service. You say that you feel there are 
several issues with the claims for these services. 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 $25 
copayment for outpatient diagnostic tests and therapeutic services.  
You have been asked to pay a $25 copayment for each radiation therapy service. This item/service falls within 
the outpatient diagnostic tests and therapeutic 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. You have been asked to pay a total of $50 ($25 copayment + 
$25 copayment = $50). Therefore, we decided that the Plan does not have to waive the copayment for each 
radiation therapy service provided on May 24, 2023, to June 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the specialist office visit provided on 
April 27, 2023, by an OON provider.  
 
You asked the Plan to provide reimbursement for the specialist office visit. You say that you have been seeing 
this provider for years, and they are familiar with your case. The Plan denied your request. The Plan says this 
service was not authorized. 
 
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 provide reimbursement for care from out-of-network providers only in cases 
involving emergencies, out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to provide reimbursement for these 
items/services. Therefore, we decided that the Plan does not have to provide reimbursement for the specialist 
office visit provided on April 27, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 billed for date of service September 
28, 2022. 
 
You asked the Plan to pay for the billed services. You say that the records describe the need for medical 
necessity. The Plan denied your request. The Plan says the billed code is 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 99214 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total 
time is spent on the date of the encounter. We find that CPT code 99214 is not supported in the medical record. The medical records show that the 
enrollee was seen for a follow up visit and medication refills. The records do not document a moderate level of 
decision making or the amount of time spent for the visit. Based on this information, we decided that Medicare 
rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code 99214 billed for date of service September 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (0037U) provided on May 17, 2023. 
 
You asked the Plan to pay for the laboratory services (0037U). You say that this testing was medically 
necessary. 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 laboratory services 
(0037U) provided on May 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transthoracic echocardiography (93308) billed for date of 
service April 12, 2023. 
 
You asked the Plan to pay for a transthoracic echocardiography. You say that you have billed the services at 
issue correctly. More than one procedure was rendered on the same date of service. The Plan denied your 
request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on June 1, 2023. Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for a transthoracic echocardiography have not been 
met. Therefore, we decided that the Plan does not have to pay for a transthoracic echocardiography (93308) 
billed for date of service April 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service June 7, 2023.  
 
You asked the Plan to pay for procedure code 99291. You say that you disagree with the 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 99291 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99291 billed for date of service June 7, 2023.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for one additional unit. We decided that the Plan does not have to pay for 
the other additional unit.   
You asked the Plan to pay for two additional units of procedure code 93970 rendered on August 5, 2022.. You 
say that this should be paid for. The Plan says that the documentation does not support that excess units were 
provided and also not documented any medical necessary reason to provide 3 units of service. 
 
We decided that the Plan has to pay for one additional unit.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 for the additional unit. Our reviewer says that the 
enrollee had bilateral upper extremity as well as bilateral lower extremity venous ultrasound studies done on 
8/5/22. These were well documented and reasonable, and two units of CPT 93970 should be paid  the 
additional unit at issue and the one unit that was already paid. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
one additional unit.  
 
We also decided that the Plan does not have to pay for the other additional unit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 for the other additional unit. Our reviewer says that 
there is no evidence of a third ultrasound of the extremities on August 5, 2023. 
 
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 other additional unit have not been met. Therefore, we decided that the Plan 
does not have to pay for the other additional unit. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methotrexate; oral, 2.5 mg (J8610). 
 
You asked the Plan to pre-approve Methotrexate; oral. You say that the enrollee has been on methotrexate for 
years. It is medically necessary that the enrollee continues methotrexate. The Plan denied your request. The 
Plan says this medicine would be covered under the member's Part D (pharmacy) benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Methotrexate; oral, 2.5 mg (J8610).