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

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on February 27, 
2023. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you were unaware of the providers 
orders, and you should not be held responsible. 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 $100 
copayment for in-network outpatient hospital services. 
 
You have been asked to pay a $100 copayment for the ultrasound. This item/service falls within the in-network 
outpatient hospital 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 
$96.16. Therefore, we decided that the Plan does not have to waive the copayment for the ultrasound provided 
on February 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the carpal tunnel surgery provided on July 
26, 2022. 
 
You asked the Plan to reduce the cost share for the carpal tunnel surgery. You say that you already paid $400, 
and are on a fixed income. 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. Your 
contract with the Plan says that there is a $400 deductible which applies to in-network outpatient surgery 
provided at an ambulatory surgical center. Your contract with the Plan also says that you must pay a $400 
copayment after meeting the deductible for in-network outpatient surgery provided at an ambulatory surgical 
center. 
 You have been asked to pay $400 towards the deductible. The item or service you asked the Plan to reduce the 
cost share for falls within the outpatient surgery benefit category. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $400 deductible which applies to in-network outpatient surgery 
provided at an ambulatory surgical center. This cost sharing is a contractual obligation that had not been met at 
the time the carpal tunnel surgery was received on July 26, 2022.  
 
You have also been asked to pay a $400 copayment for the carpal tunnel surgery. This item/service falls within 
the outpatient surgery benefit category. You have been asked to pay a total of $800 ($400 deductible + $400 
copayment = $800). 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 cost share for the carpal tunnel surgery 
provided on July 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 1, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the 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 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 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 an office visit provided on February 1, 2023, by an 
out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the psychological testing evaluation services (96130 
x6), neuropsychological testing evaluation services (96132 x6), psychological or neuropsychological test 
administration and scoring by technician (96138 x6), alcohol and/or substance (other than tobacco) abuse 
structured assessment (G0396), and annual depression screening (G0444).  
 
You asked the Plan to pre-approve the services. You say that this testing is not self-administered or scored, but 
are performed, documented, and scored by a technician per current procedural terminology (CPT) code 96138 
requirements.  The Plan denied your request. The Plan says  the measures requested are all brief screening tests 
that the enrollee can complete independently in significantly less time than is being requested. The Plan also 
says this appeal request for 15 hours of testing is not reasonable or necessary at this time.  
 
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 services. Our physician reviewer 
found this testing utilizing LCD L34646, is intended to diagnose and characterize the neurocognitive effects of 
medical disorders that impinge directly on or indirectly on the brain including detection of neurologic disease 
based on quantitative assessment of neurocognitive abilities, differential diagnosis between psychogenic and 
neurogenic syndromes, delineation of neurocognitive effects of central nervous system disorders, 
neurocognitive monitoring of recovery or progression of central nervous system disorders or assessment of 
neurocognitive function for the formulation of rehabilitation and/or management strategies among individuals 
with neuropsychiatric disorders. this enrollee does not meet the criteria because the enrollee is diagnosed with 
chronic pain, and it is unclear how the testing would be used to benefit this enrollee. Therefore, the services are 
not medically necessary or reasonable. It is unclear what questions are to be answered by neuropsychological 
testing. 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 not been met. Therefore, we decided that the Plan 
does not have to pre-approve the psychological testing evaluation services (96130 x6), neuropsychological 
testing evaluation services (96132 x6), psychological or neuropsychological test administration and scoring by 
technician (96138 x6), alcohol and/or substance (other than tobacco) abuse structured assessment (G0396), and 
annual depression screening (G0444).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on January 25, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for a home visit. You say that the assisted living facility is responsible to obtain 
prior authorization for all of their patients. The Plan denied your request. The Plan says the 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 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 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 a home visit provided on January 25, 2023, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Barostim NEO device. 
 
You asked the Plan to pre-approve the Barostim NEO device. You say that the Barostim NEO device is 
medically necessary. The Plan denied your request. The Plan says the requested Barostim NEO device 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 Barostim NEO device. Our 
reviewer says that the requested Barostim NEO device is not considered medically reasonable and necessary. 
Our physician reviewer found this is a request for a Barostim NEO device for an enrollee with ischemic 
cardiomyopathy with chronic hypotension whose primary symptom is fatigue. The enrollee does have 
shortness of breath but this is on climbing 3-4 flights of stairs. The most recent American College of Cardiology and American Heart Association 2022 Congestive Heart Failure Guidelines does not recommend 
implantation of the NEO-Barostim device. The review has determined that the Barostim NEO device at issue in 
this case is not medically reasonable and 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 Barostim NEO device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Barostim NEO device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the care planning assessment provided on December 30, 
2022. 
 
You asked the Plan to pay for the care planning assessment. 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 care planning 
assessment provided on December 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that you were told by your provider that 
this could be covered up to 80 years of age. The Plan denied your request. The Plan says you are not between 
50 and 77 years of age. 
 The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that you are not 50 to 77 years of age. Therefore, we 
decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a respiratory assist device, bi-level pressure capability, 
without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist 
device with continuous positive airway pressure device) (E0470). 
 
You asked the Plan to pre-approve a respiratory assist device. You say that the device is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for approval of the requested 
device. 
 
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 respiratory assist device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found based on the medical records provided there is no documentation that the 
bilevel positive airway pressure (BiPAP) device at issue in this case meets all Medicare and LCD L33718 
criteria for medically reasonable and necessary for the enrollee. Provided records in this case do not document 
results of a qualifying sleep test to meet Medicare LCD criteria for the BiPAP device. 
 
 
 
 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 respiratory assist device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a respiratory assist device, bi-level pressure capability, without backup rate 
feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous 
positive airway pressure device) (E0470).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 screening (0202U) provided October 6, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that please review and reprocess this appeal and 
reconsider with the attached records. The Plan denied your request. The Plan says this service does not meet 
the coverage requirements. 
 
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. This code is listed as a non-covered code per Local Coverage Article 
A58741. Based on this information, we decided that Medicare rules for coverage of the laboratory service have 
not been met. Therefore, we decided that the Plan does not have to pay for the COVID-19 screening (0202U) 
provided October 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a subcutaneous cardiac rhythm monitor (implantable 
loop recorder (ILR) device) (33285).  
 
You asked the Plan to pre-approve the device. You say that this device is covered to detect, characterize, and 
document symptomatic transient arrhythmias, and initiate, revise, or discontinue arrhythmic drug therapy. You 
say that this clinical scenario of cryptogenic stroke as well as management of arterial fibrillation. You also say 
that this should be approved. The Plan denied your request. The Plan says the requested device is not 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 the device. Our physician reviewer 
found the requested authorization for an implantable cardiac monitor (ICM) is medically necessary. There is no 
documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent 
indication for an ICM. In summary, there is insufficient documentation to support the medical necessity for 
insertion of an ICM in this 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 the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a subcutaneous cardiac rhythm monitor (implantable loop recorder (ILR) device) (33285).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs 
provided on January 20, 2023. 
 
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. You say that you disagree 
with the coinsurance. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for Medicare Part B prescription drugs. This item/service falls 
within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total allowed amount for the prescription drugs is $390.60. You are 
being asked to pay $78.12 ($390.60 x 20% = $78.12). Therefore, we decided that the Plan does not have to 
waive the coinsurance for Medicare Part B prescription drugs provided on January 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the morphometric analysis (88377) provided on March 2, 
2023. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Review of the file shows that code 88377 was billed with a total of six (6) units. One (1) unit was billed under a 
claim and five (5) units were billed under a different claim, which was already paid for a total of 6 units. Per 
the Centers for Medicare & Medicaid Services (CMS) Practitioner Services MUE table that was in affect at the 
time of this date of service the allowed amount of units per day for this code was 5. The provider has not 
documented any medically necessary reason for performing extra units in excess of the 5 allowed. Based on 
this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we 
decided that the Plan does not have to pay for the morphometric analysis (88377) provided on March 2, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services (G0162) provided from June 28, 
2022, through July 11, 2022. 
 You asked the Plan to pay for the home health services . You say that the claim should be paid. The Plan 
denied your request. The Plan says the NOA was not received timely. As such, this final claim was correctly 
denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
The Plan did not receive the NOA prior to it being included within the appeal request on April 25, 2023. As 
this is the first submission of the NOA, the submission is beyond the required time limit and as such the denial 
is upheld. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
(G0162) provided from June 28, 2022, through July 11, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve targeted psychological case management services.  
 
You asked the Plan to pre-approve the targeted case management services. You say that it is felt that the 
requested care is medically necessary.  The Plan denied your request. The Plan says the targeted psychiatric 
condition, symptoms, and behaviors documented are not appropriate for psychosocial rehabilitation.  
 
The Plan follows Medicare rules. Medicare rules say that certain psychological services are considered 
medically necessary, but maintenance care is only covered when there is a specific reason noted with clear 
goals.  
 
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 targeted case management services. Our reviewer says that the requested case management services are not shown to be medically necessary for the 
enrollee.  Our physician reviewer found there is no indication the enrollee requires assistance to secure housing 
or is at a risk for needing a higher level of psychiatric care. There is no clear indication that the enrollee would 
require Targeted Case Management services. 
 
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 targeted case management services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve targeted psychological case management services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (87631-59), noninvasive ear or pulse 
oximetry for oxygen saturation (94761-59) and additional supplies (99072-59) provided on December 19, 
2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Current Procedural Terminology (CPT) code 87631-59 (1 Unit) remains 
not supported. Test providers must receive an identifier specific to the applicable test and submit the test 
assigned identifier with the claim for reimbursement. Procedure 94761 has a status indicator of T on the CMS 
National Physician Fee Schedule (NPFS) Relative Value (RVU) file. This means this service is always bundled 
into another payable physician service, 94664, billed the same day by the same provider. Please refer to the 
CMS PFS RVU page to download the PFS RVU spreadsheet that corresponds to the calendar year of the date-
of-service. We find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This 
means that procedure code 99072 is not separately payable. We looked at 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 the laboratory service (87631-59), noninvasive ear or pulse 
oximetry for oxygen saturation (94761-59) and additional supplies (99072-59) provided on December 19, 
2022.