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

 
We decided that the Plan does not have to waive the cost sharing for the office visit provided by an in-network 
provider on August 18, 2022, and the remote physiologic monitoring services provided by an in-network 
provider on August 31, 2022, September 27, 2022, and January 20, 2023. 
 
You asked the Plan to waive the cost sharing for the office visit, and the remote physiologic monitoring 
services. You say that you think that these services should be covered. The Plan denied your request. The Plan 
says this cost sharing was charged correctly. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for in-network provider and professional services provided in a primary care provider (PCP) office 
in 2022, and a $5 copayment for in-network provider and professional services provided in a primary care 
provider (PCP) office in 2023. 
 
You have been asked to pay a cost share of $23.81 for the office visit ($119.06 allowed amount x .20 = 
$23.81). You have been asked to pay a cost share of $18.14 for the remote physiologic monitoring services 
provided on August 31, 2022, and September 27, 2022 ($90.70 allowed amount x .20 = $18.14). You have also 
been asked to pay a $5 copayment for the remote physiologic monitoring services provided on January 20, 
2023. These items/services fall within the physician/practitioner services, including doctor's office visits 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 office visit provided by an in-network 
provider on August 18, 2022, and the remote physiologic monitoring services provided by an in-network 
provider on August 31, 2022, September 27, 2022, and January 20, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a physical medicine procedure (97139) and infrared 
therapy (97026). 
 
You asked the Plan to pre-approve a physical medicine procedure and infrared therapy. You say that this 
service needs to be approved due to your condition. The Plan denied your request. The Plan says infrared 
therapy is not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the use of infrared and/or near-infrared light 
and/or heat, including monochromatic infrared energy, is non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a physical medicine procedure and infrared therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a physical medicine procedure (97139) and infrared therapy (97026).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy (36475, 36476, 76937). 
 
You asked the Plan to pre-approve endovenous ablation therapy. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. 
 
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 endovenous ablation therapy. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the record indicates 
that the enrollee has varicose veins. The record provided is insufficient to document that the enrollee satisfies 
the elements of the coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovenous ablation therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve endovenous ablation therapy (36475, 36476, 76937).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 87150 billed for date of service January 19, 
2023. 
 
You asked the Plan to pay for procedure code 87150. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 87150 is bundled into payment for code 87500. 
 
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 87150 
is a column II code to column I code 87500. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted. The -XU modifier is not supported as a separate and distinct 
procedural service. Medicare billing criteria have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 87150 billed for date of service January 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88342 billed for date of service February 28, 
2023.  
 
You asked the Plan to pay for procedure code 88342. 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 88342 is 4. The MAI value for this code is 3. You billed 5 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88342 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88342 billed for date of service February 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87634 billed for date of service March 11, 
2022. 
 
You asked the Plan to pay for procedure code 87634. You say that this service was necessary and was reported 
correctly. The Plan denied your request. The Plan says payment for code 87634 is bundled into payment for 
code 87632. 
 
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 87634 
is a column II code to column I code 87632. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 87634 billed for date of service March 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a chondroplasty and medial meniscectomy of the left 
knee. 
 
You asked the Plan to pre-approve a knee surgery. You say that the enrollee has failed more conservative 
alternatives. The Plan denied your request. The Plan says the medical criteria have not been met for this 
surgery. 
 
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 knee surgery. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, less 
invasive conservative care measures is not evident. Moreover, the magnetic resonance imaging (MRI) does not corroborate a meniscal tear that would require surgical repair.  
 
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 knee surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a chondroplasty and medial meniscectomy of the left knee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a discission of secondary membranous cataract for the 
right eye. 
 
You asked the Plan to pre-approve cataract procedure. You say that you are currently straining again to be able 
to see. The Plan denied your request. The Plan says the medical criteria for this procedure have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve cataract procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is not noted to have visual acuity worse of 20/50 or worse, or evidence of 
glare testing causing loss of visual acuity. There is no documentation that the visual acuity is expected to 
improve, or that there is not proper visualization of the retina for necessary treatment such that the YAG laser 
capsulotomy is needed to improve the view of the dilated fundus exam. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cataract procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a discission of secondary membranous cataract for the right eye.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 10, 2023. 
 
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 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 January 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an attendant control (E2331). 
 
You asked the Plan to pre-approve an attendant control. The Plan denied your request. The Plan says the 
requested service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that if an attendant control (E2331) is provided in 
addition to a beneficiary-operated drive control system, it will be denied as non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an attendant control have not been met. Specifically, the record shows that the enrollee has been 
approved for the group 3 power wheelchair with the upgraded drive system (expandable controller, electronic 
connection between 2 or more power seating motors, and the harness). Therefore, we decided that the Plan 
does not have to pre-approve an attendant control (E2331).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99000 billed for date of service June 7, 2022. 
 
You asked the Plan to pay for procedure code 99000. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99000 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code 99000 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99000 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99000 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99000 billed for date of service June 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365 and 96366 billed for date of service 
March 27, 22023. 
 
You asked the Plan to pay for the billed services. You say that the medical records support the charges. The 
Plan denied your request. The Plan says the billed codes 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. 
 
We find that CPT codes 96365 and 96366 are not supported in the medical record. There is a more accurate 
code available to describe the services provided. 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 codes 96365 and 96366 billed for date of service March 27, 22023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each ambulance service provided on March 
16, 2023. 
 
You asked the Plan to waive the copayment for each ambulance service. You say that this was the only safe 
way you could be transferred. 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 $350 
copayment for ambulance services. 
 
You have been asked to pay a $350 copayment for each 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 copayment for each ambulance 
service provided on March 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous implantation of neurostimulator 
electrode array. 
 
You asked the Plan to pre-approve nerve blocker. You say that the enrollee is in a lot of pain. The Plan denied 
your request. The Plan says there is no documentation showing the enrollee got better with a trial of this nerve 
blocker. 
 
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 nerve blocker. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation is not evident regarding the results from the trial showing sustained 
functional benefit. Moreover, there is limited published, large-scale, long-term peer-reviewed literature that 
shows this request to be an effective and/or safe treatment for the noted pathology. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nerve blocker have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a percutaneous implantation of neurostimulator electrode array.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the neuromonitoring services provided on January 3, 2023. 
 
You asked the Plan to pay for the neuromonitoring services. You say that your Medicare providership has been 
reactivated, effective September 22, 2022. You also say that this should be paid. The Plan denied your request. 
The Plan says that that payment cannot be made to a provider that has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the Plan did not substantiate that the denial that the provider has 
opted out of Medicare. Additionally, there is no Evidence of Benefits (EOB) provided to support the denial. 
Therefore, we decided that the Plan has to pay for the neuromonitoring services provided on January 3, 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: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve an extracranial bilateral study (93880) and extracranial unilateral 
or limited study (93882). 
 
You asked the Plan to pre-approve extracranial studies. You say that the enrollee has a history of carotid 
stenosis and would need monitoring. You also say that the enrollee has underlying dyslipidemia/aortic valve 
stenosis which increases their risk. The Plan denied your request. The Plan says that the Plan criteria were not 
met, and the services would be considered not medically necessary. 
 
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 extracranial studies. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found given the enrollee's uncontrolled risk factors, there is concern for progression of carotid artery 
stenosis. Worsening of carotid narrowing further increases the enrollee's risk for serious conditions such as 
cerebral vascular accident (CVA) and carotid artery dissection. Our reviewer also found that a repeat bilateral 
carotid artery duplex study 2 to 3 years later is appropriate and medically necessary to prevent further 
progression of disease and prevent morbidity and mortality. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of extracranial studies have been met. Therefore, we decided that the Plan has to 
pre-approve an extracranial bilateral study (93880) and extracranial unilateral or limited study (93882).  
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the services (87652) provided on February 14, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that 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 87652 is "Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, 
quantification". 
 
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 services. Our reviewer says that the use of code 87652 is 
not supported by the records provided. Our reviewer found that the record states that streptococcus pyogenes 
was tested for and was negative. The methodology is explained in the results. A negative result would not 
produce further data. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
the services (87652) provided on February 14, 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.