Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the specialist office visit and the knee brace 
provided on July 21, 2023.  
 
You asked the Plan to waive the cost share for the specialist office visit and the knee brace. You say that you 
should not be held responsible for these charges. 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 $50 
copayment for each Tier 2 Medicare-covered specialist visit. The Plan contract also says that enrollee must pay 20% coinsurance for Tier 2 durable medical equipment. 
 
You have been asked to pay a $50 copayment for the specialist visit. This item/service falls within the 
physician/practitioner services, including doctors office visit benefit category. 
 
You have been asked to pay $111.76, which is 20% coinsurance of the allowed amount for the knee brace 
($558.82 allowed amount x 20% coinsurance = $111.76). You have been asked to pay a total of $161.76 ($50 
copayment + $111.76 coinsurance = $151.76). This item falls within the durable medical equipment 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 share for the specialist office visit and the knee brace 
provided on July 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a needle biopsy provided on August 18, 
2023. 
 
You asked the Plan to waive the copayment for a needle biopsy. You say that you do not agree with this 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for outpatient hospital services. 
 
You have been asked to pay a $250 copayment for a needle biopsy. This item/service falls within the 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. Therefore, we decided that the Plan does not have to waive the copayment for a needle biopsy 
provided on August 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT) (77373, 
77470). 
 
You asked the Plan to pre-approve SBRT. You say that SBRT is medically necessary for the treatment of the 
enrollee's solitary hepatic metastasis. The Plan denied your request. The Plan says there is no good evidence the 
SBRT treatment is safe or effective for the enrollee's cancer. 
 
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 SBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found while SBRT for oligometastases to the liver is a standard approach, generally SBRT is only 
indicated when radiation, surgery or other local therapy addresses all sites of disease. It does not make sense 
(and there is no data supporting the approach) to treat a liver lesion (with significant risks as described in the 
clinical records) with other sites of active disease that are not treated. The reviewer assumes the enrollee would 
be offered systemic therapy, in which case SBRT to the liver does not make sense if there is active disease in 
the neck that is managed with systemic therapy alone. The decision is unfavorable for SBRT as treating one 
site of disease with other sites of active disease (even in oligometastatic) is not an accepted standard of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve stereotactic body radiation therapy (SBRT) (77373, 77470).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
September 05, 2023. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you were unable to pick 
an in-network provider. 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 ambulance services. 
 
You have been asked to pay a $325 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 waive the copayment for the ambulance 
services provided on September 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a first office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that the requested service is a necessity for your 
care. The Plan denied your request. The Plan says rules for coverage for OON services have not been met. 
 
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 first office visit to be provided by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3 
 You asked the Plan to pre-approve Gelsyn-3. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee did not meet the step therapy requirements. 
 
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 the injections. Our physician reviewer 
found that the Plan requires a trial of Orthovisc or Supartz FX before they will approve Gelsyn-3. Our 
physician reviewer found that based on the medical records provided there is no indication that the enrollee has 
tried and failed the required drugs. Our physician reviewer found that there is no indication that the Plans 
required drugs would likely be less effective and/or likely have adverse effects for the enrollee.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network urology continuation of care. 
 You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the treatments recommended are standard urological treatments that are available 
through in-network providers. 
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that based on the 
medical records provided there is no documentation that this enrollee is currently receiving any active 
treatment and/or medical management of his/her condition that makes it medically necessary for this enrollee to 
continue care with the out-of-network urology provider as requested. There is no documentation that there 
anything unique about this enrollee's condition that would make it medically necessary for her to continue care 
with the out-of-network provider. There is documentation that the health plan has in-network urology 
specialists who have the qualifications and expertise necessary to meet the current medical Standards of Care 
required for treatment of the enrollee's condition. The enrollee's medical management and/or follow-up care 
can be safely transitioned to an in-network urology specialist at this time. 
 
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 an out-of-network urology continuation of care.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99285) provided on May 9, 2023. 
 
You asked the Plan to pay for the emergency room services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect 
the services provided.   
 
In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the 
evaluation and management of a patient which requires three components (taking into account the urgency of 
the clinical condition or the patient's mental status): 
 
1. a comprehensive history; 
2. a comprehensive examination; and 
3. medical decision making of high complexity.  
In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate 
significant threat to life or physiologic function.  
 
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 the emergency room services Our reviewer 
says that the records do not support the billed service. Our reviewer found the provided records do not show 
medical decision making of a high complexity. 
 
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 emergency room services have not been met. Therefore, we decided that the 
Plan does not have to pay for emergency room services (99285) provided on May 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair transit option, plate cover, arm pads, and 
headrest cushion. 
 
You asked the Plan to pre-approve wheelchair transit option, plate cover, arm pads, and headrest cushion. You 
say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the requested items 
are not a covered benefit.  
The Plan must follow Medicare rules. Medicare rules say that wheelchair accessories are only covered for 
certain indications. 
 
We looked at the file and Medicare rules. The requested transit option and foot plate do not serve a purpose that 
is primarily medical in nature. These items are available to the general public and would be helpful even to 
those who are not sick or injured. The requested arm pads are a replacement code and cannot be covered on 
initial issue. In addition, arm pads are unbundled from the power wheelchair base and cannot be requested 
separately. The requested headrest cushion is miscoded as it was requested with code K0108 but has a specific 
Healthcare Common Procedure Coding System (HCPCS) code. Based on this information, we decided that 
Medicare rules for coverage of wheelchair transit option, plate cover, arm pads, and headrest cushion have not 
been met. Therefore, we decided that the Plan does not have to pre-approve wheelchair transit option, plate 
cover, arm pads, and headrest cushion.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 66984-54-79-LT provided September 7, 
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 service is not supported by the records. 
 
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 66984 is extracapsular cataract removal with insertion of 
intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or 
phacoemulsification); without endoscopic cyclophotocoagulation. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the service. Our reviewer found the procedure note for this surgery was not found to correlate with this submitted code for the date, September 7, 2023. Therefore, the 
documentation does not sufficiently support procedure code 66984-54-79-LT provided on September 7, 2023. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 66984-54-79-LT provided September 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services (72141-26, 72146-26, 72148-26) 
provided May 3, 2023. 
 
You asked the Plan to pay for the radiology services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
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 72141 is magnetic resonance (eg, proton) imaging, spinal 
canal and contents, cervical; without contrast material. The definition of 72146 is magnetic resonance (eg, 
proton) imaging, spinal canal and contents, thoracic; without contrast material. The definition of 72148 is 
magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast material. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the radiology services. Our reviewer found the provided 
documentation does not include radiology notes associated with this date to support these codes. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the radiology services have not been met. Therefore, we decided that the Plan 
does not have to pay for the radiology services (72141-26, 72146-26, 72148-26) provided May 3, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service August 14, 
2023.  
 You asked the Plan to pay for procedure code 76641. You say that the service was billed correctly and should 
be paid. 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 76641 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 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service August 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services described by codes 
99223 billed on June 22, 2023, 99232 billed on June 23, 2023, and 99238 billed on June 24, 2023. 
 
You asked the Plan to pay for 99223, 99232, and 99238. You say that 99223, 99232, and 99238 should be paid 
as billed because they are supported in the medical record. The Plan denied your request. The Plan says 99223, 
99232, and 99238 are denied because the medical records provided do not contain a date of service or the name 
of the enrollee receiving the services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 99223, 99232, and 99238 are not supported in the medical record. Specifically, we 
confirmed that while there are evaluation and management notes included in the record, none of these 
evaluation and management notes document the name of the enrollee receiving care or the date that the services took place. While there are charge tickets included in the provided documentation, a charge ticket is not 
considered part of the official medical record. As such, the validity and accuracy of the billed evaluation and 
management services cannot be verified. Based on this information, we decided that Medicare rules for 
coverage of 99223, 99232, and 99238 have not been met. Therefore, we decided that the Plan does not have to 
pay for the evaluation and management services described by codes 99223 billed on June 22, 2023, 99232 
billed on June 23, 2023, and 99238 billed on June 24, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry home visit services (99348, 11721, 1125F, 
3008F, 3077F, 3079F) provided on July 12, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the home visit. You say that the enrollee was seen by your office for care of their 
feet due to other medical conditions, vascular disease, difficulty walking and pain in their feet. The Plan denied 
your request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 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 the podiatry home visit services (99348, 11721, 
1125F, 3008F, 3077F, 3079F) provided on July 12, 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 an eye appointment. 
 
You asked the Plan to pre-approve an eye visit. You say that you would like this to be reviewed again. The 
Plan denied your request. The Plan says there are other providers available who are in-network, who are within 
the Medicare allowable distance from your residence. 
 
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is 
considered accessible to an enrollee if contract providers are available within reasonable distance and travel 
time from the enrollees home. The Plan says that enrollees must use contract providers.  
 
The provider is a non-contract provider. We were able to confirm that the Plan has contract providers located 
within reasonable distance and travel time from your home who can provide an eye visit. Under Medicare 
rules, this means that contract providers are accessible to you. Therefore, we decided that the Plan does not 
have to pre-approve an eye appointment.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on April 13, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services are not covered when provided by an OON provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the 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 the office visit provided on April 13, 2023, by an 
out-of-network (OON) provider.