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

 
We decided that the Plan does not have to pay for the hemodialysis procedure provided on August 18, 2023. 
 
You asked the Plan to pay for the hemodialysis procedure. 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 hemodialysis 
procedure provided on August 18, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve parathyroid planar imaging (including subtraction, when 
performed) (78070). 
 
You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your 
request. The Plan says this request is duplicative. 
 
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 imaging. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the plan has already approved a better and more detailed test - CPT 78071. There is no valid reason 
for the duplicative request for CPT 78070. 
 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 imaging have not been met. Therefore, we decided that the Plan does not 
have to pre-approve parathyroid planar imaging (including subtraction, when performed) (78070).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0668, E0656, 
E0652) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the pneumatic compression device. You say that this device is medically 
necessary. The Plan denied your request. The Plan says there are network providers available. 
 
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 at issue in this appeal. We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve a pneumatic 
compression device (E0668, E0656, E0652) to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgery provided on July 18, 
2023. 
 
You asked the Plan to waive the copayment for the outpatient surgery. You say that you want to appeal the 
amount being charged. 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 $275 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $275 copayment for the outpatient surgery. This item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 outpatient surgery provided 
on July 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twelve chiropractic visits to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve twelve chiropractic visits. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says the service can be provided by an in-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 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 twelve chiropractic visits 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 twelve chiropractic visits to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve prostatic arterial embolization (PAE). 
 
You asked the Plan to pre-approve prostatic arterial embolization. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says that it is considered an 
experimental technique to treat symptomatic benign prostatic hyperplasia (BPH). 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 prostatic arterial embolization. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found that due to symptoms of lower urinary tract obstruction and a desire for a 
minimally invasive procedure the requested prostatic artery embolization procedure should be approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prostatic arterial embolization have been met. Therefore, we decided that the 
Plan has to pre-approve prostatic arterial embolization (PAE).  
 
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 pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the procedure. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says experimental and investigational procedures are not covered. 
 
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 procedure. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no imaging showing only modic changes without facet degenerative joint disease or 
stenosis. The cause of pain is not clear. 
 
 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of the intraosseous basivertebral 
nerve. 
 
You asked the Plan to pre-approve thermal destruction of the intraosseous basivertebral nerve. You say that 
you are requesting reconsideration for the denied claim. The Plan denied your request. The Plan says it is 
considered experimental/investigational. 
 
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 thermal destruction of the intraosseous 
basivertebral nerve. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found there is no magnetic resonance imaging 
(MRI) showing only modic changes without facet degenerative joint disease (DJD) or stenosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of thermal destruction of the intraosseous basivertebral nerve have not been met. 
Therefore, we decided that the Plan does not have to pre-approve thermal destruction of the intraosseous 
basivertebral nerve.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the ambulance services provided on 
August 08, 2023. 
 
You asked the Plan to reduce the copayment for the ambulance services. You say that you are asking the plan 
to reduce your ambulance copay to $140 as you are on a fixed income and cannot afford to pay the applicable 
copay amount of $280. 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 $280 
copayment for ambulance services. 
 
You have been asked to pay a $280 copayment for the ambulance services. 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 reduce the copayment for the ambulance 
services provided on August 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 03, 2023. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary, there is a referral on 
file for this patient. Please review and pay. 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 provided 
on July 03, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on November 17, 2022. 
 
You asked the Plan to pay for the lab testing. You say that if the ordering physician failed to obtain proper 
authorization prior to services being rendered the lab should not be held responsible. 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 lab testing provided 
on November 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 74183 and 72197 for date of service 
September 12, 2023. 
 
You asked the Plan to pay for procedure codes 74183 and 72197. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 74183 is magnetic resonance (eg, proton) imaging, 
abdomen; without contrast material(s), followed by with contrast material(s) and further sequences. 
The CPT Code Manual definition of code 72197 is magnetic resonance (eg, proton) imaging, pelvis; without 
contrast material(s), followed by contrast material(s) and further sequences. 
  
We find that CPT code 74183 and 72197 is not supported in the medical record. Specifically, the 
documentation does not support that magnetic resonance (eg, proton) imaging, abdomen; without contrast 
material(s), followed by with contrast material(s) and further sequences was performed on the billed date of 
service. 
 
The documentation submitted does not support that magnetic resonance (eg, proton) imaging, pelvis; without 
contrast material(s), followed by contrast material(s) and further sequences was performed on the billed date of 
service. 
Based on this information, we decided that Medicare rules for coverage of procedure codes 74183 and 72197 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 74183 and 
72197 for date of service September 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service June 6, 2023. 
 
You asked the Plan to pay for procedure code 81456. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 81456 is bundled into payment for code 81455.  
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 81456 
is a column II code to column I code 81455. The -59 modifier is not supported as a separate and distinct 
procedural service.. 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 81456 billed for date of service June 6, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on July 
13, 2023, to July 17, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you feel that you 
should not have to pay. 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 $325 
copayment for inpatient hospital care. 
 
You have been asked to pay a $325 copayment for the inpatient hospital stay. This item/service falls within the 
inpatient hospital care 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 $1,300 for the inpatient hospital stay ($325 
copayment x 4 days = $1,300). You have not been charged for the day you were discharged. Therefore, we 
decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on July 13, 
2023, to July 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair/tub stool.  
 
You asked the Plan to pre-approve a shower chair. You say that you are having knee surgery and you need this 
item to bathe safely after the operation. 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/tub stool.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 subsequent deep sedation/general anesthesia. 
 
You asked the Plan to pre-approve 2 subsequent deep sedation/general anesthesia. You say that you would like 
to request reconsideration of the denied claim and that the services requested are medically necessary. 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. Therefore, 
we decided that the Plan does not have to pre-approve 2 subsequent deep sedation/general anesthesia.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the ambulance service (A0999) provided 
on July 14, 2023.  
 
You asked the Plan to waive the cost sharing for the ambulance service. You say that you had fainted. You say 
that the restaurant called the ambulance. You also say that you should not have to pay a copayment since you 
were not taken to the hospital. 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 $225 
copayment for ambulance services.  
 You have been asked to pay a $225 copayment for the ambulance service. 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 cost sharing for the ambulance 
service (A0999) provided on July 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies billed with 
codes A4238 and A4239 for June 14, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says no more than a 90-day supply may be dispensed at a time. 
 
The Plan must follow Medicare rules. The rules say that only one (1) UOS of code A4238 or A4239 may be 
billed at a time and no more than a 90-day supply may be dispensed to the beneficiary at a time 
 
We looked at the file and Medicare rules. The file shows that more than one unit of service for these codes was 
billed in a 90-day time period. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the continuous 
glucose monitor (CGM) supplies billed with codes A4238 and A4239 for June 14, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. The Plan denied your request. The Plan says that 
a home ventilator is not medically necessary for this patient because their needs can be met with an alternative 
device such as a BiPAP device with average volume-assured pressure support (AVAPS).  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 home ventilator system. Our reviewer 
says that a home ventilator system is medically necessary. Our physician reviewer found that the enrollee has 
been on non-invasive therapy with a good outcome and compliance. Therefore, to change modes is substandard 
of care and not indicated as the best practice. 
 
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 home ventilator system have been met. Therefore, we decided that the Plan 
has to pre-approve a home ventilator system.  
 
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.