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

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar 
spine. 
 
You asked the Plan to pre-approve the MRI. You say that an updated MRI is needed to compare to the previous 
study. The Plan denied your request. The Plan says the denial of authorization for the MRI is correct, because 
records do not show that the enrollee has had a trial and failure of a recent 6-week provider directed treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the 
MRI is not medically necessary. Our physician reviewer found that there is no recent trial of physical therapy 
for back pain. 
 
  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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 25600 and 99283 rendered on December 24, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is:  CPT 25600: 
 
Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed 
treatment of fracture of ulnar styloid, when performed; without manipulation 
 
CPT 99283: 
 
Emergency department visit for the evaluation and management of a patient, which requires these 3 key 
components: An expanded problem focused history; An expanded problem focused examination; and Medical 
decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other 
qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and 
the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity." 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 25600, the 
procedure report documents that the enrollee was placed in a splint and referred to orthopedic surgery for an 
outpatient follow-up. In this case, there is insufficient documentation to verify the fracture treatment. There is a 
more specific code to report for the application of a splint.  
 
In terms of CPT 99283, this was reported with modifier 57. However, the procedure report documents that the 
enrollee was referred to orthopedic surgery. The documentation does not support the criteria for modifier 57, 
which is that the evaluation and management service must have resulted in the initial decision to perform 
surgery either the day before a major surgery (90 day global) or the day of a major surgery. Therefore, CPT 
99283 with appended modifier 57 cannot be verified. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 25600 and 99283 rendered on December 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injection of non-compounded foam sclerosant 
(36465, 36466). 
 
You asked the Plan to pre-approve the injection of non-compounded foam sclerosant. You say that you can't 
walk and you do not want to continue to be in pain. The Plan denied your request. The Plan says the requested 
procedure does not meet the requirements for approval.  
 
The Plan follows Medicare rules. Medicare rules say that Medicare will consider invasive procedures (only 
with the techniques outlined in this local coverage determination (LCD) and under the conditions described) as 
reasonable and necessary when documentation in the medical record includes a history, physical examination, 
CEAP clinical classification, and a venous duplex scan documenting reflux (>500 msec). 
 
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 injection of non-compounded foam 
sclerosant. Our reviewer says that the documentation does not meet coverage criteria. Our physician reviewer 
found the coverage criteria require that your symptoms be due to the varicose veins to be treated. In this case, it 
is documented that you are unable to walk and are in severe pain. This is disproportionate to symptoms that 
would be expected due to saphenous vein insufficiency. You have a history of lumbar spine stenosis severe 
enough to warrant neurosurgical evaluation. Until this issue is resolved, it is unlikely to expect that you would 
enjoy any meaningful improvement from saphenous vein ablation. Additionally, the materials provided do not 
demonstrate the absence of a deep venous occlusive process or severe reflux in the veins to be treated.  
Therefore, the Plans determination cannot be overturned. 
 
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 injection of non-compounded foam sclerosant have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the injection of non-compounded foam sclerosant 
(36465, 36466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81184 billed for date of service September 
20, 2022. 
 You asked the Plan to pay for procedure code 81184. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 81184 is bundled into payment for code 81185. 
 
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 81184 
is a column II code to column I code 81185. 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 81184 billed for date of service September 20, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty at L1 and L2.  
 You asked the Plan to pre-approve kyphoplasty at L1 and L2. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that PVA (percutaneous vertebroplasty (PVP) or 
percutaneous kyphoplasty (PKP)) is covered in patients who meet specific criteria. 
 
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 kyphoplasty at L1 and L2. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found detailed documentation is not 
evident regarding the worsening of pain. Additionally, there is no documentation of a progression of the body 
height loss, greater than 25% vertebral body height loss, kyphotic deformity, or a severe impact on daily 
activities. Moreover, there is magnetic resonance imaging (MRI) corroboration of retropulsion and other 
plausible causes of pain. Therefore, the enrollee does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty at L1 and L2 have not been met. Therefore, we decided that the 
Plan does not have to pre-approve kyphoplasty at L1 and L2.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for a psychiatric evaluation, an office visit, 
and an inpatient hospital stay provided from May 1, 2023, to May 22, 2023. 
 
You asked the Plan to reduce the copayments for a psychiatric evaluation, an office visit, and an inpatient 
hospital stay. You say that you would like for these services to be reprocessed at the in-network benefit level. 
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 $65 
copayment for out-of-network provider and professional services. Your contract with the Plan also clearly says 
that you must pay a $495 copayment per day, days 1 to 27 and a $0 copayment per day, for days 28 to 90 of an 
out-of-network inpatient hospital stay. 
 
You have been asked to pay a $65 copayment for a psychiatric evaluation provide don May 1, 2023. You have 
also been asked to pay $22.52, which is less than the standard copayment for the office visit provided on May 
22, 2023. These items/services fall within the physician/practitioner services, including doctor's office visits 
benefit category. You have also been asked to pay a $495 copayment per day, for days 1 to 13 of the inpatient 
hospital stay provided from May 2, 2023, to May 25, 2023. You have been asked to pay a total of $6,435 ($495 
copayment x 13 days = $6,435). 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. Therefore, we decided that 
the Plan does not have to reduce the copayments for a psychiatric evaluation, an office visit, and an inpatient 
hospital stay provided from May 1, 2023, to May 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the ventilator is necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee does not meet the requirements for a home ventilator. 
 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. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document 
that the home ventilator is being requested for use in an average volume assured pressure support (AVAPS) 
mode which is a modality that could be provided by a bilevel positive airway pressure (BiPAP) device with 
AVAPS and a back-up rate. Provided records do not document trial and failure of a BiPAP device with 
AVAPS and a back-up rate. 
 
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 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on May 24, 2023. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you say that you dont understand 
why the ultrasound was not paid for. 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 $110 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $110 copayment for an ultrasound. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies 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 $100.90. Therefore, we decided that the Plan does not have to waive the copayment 
for an ultrasound provided on May 24, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77021 rendered on April 12, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 77021-26 (1 units) remains 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 77021 is "Magnetic resonance imaging guidance for 
needle placement (eg, for biopsy, needle aspiration, injection, or placement of localization device) radiological 
supervision and interpretation." 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that there is no documentation to support that CPT 77021 was performed in this case. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 77021 rendered on April 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on April 14, 2023. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration stating that the 
services were medically necessary and you have submitted medical documentation to support. 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 lab testing provided on 
April 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on January 3, 2023, to March 29, 
2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your $2,000 annual maximum 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. The record 
shows your $2,000 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay 
for dental services provided on January 3, 2023, to March 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network acute inpatient stay June 8, 
2023, to June 12, 2023. 
 
You asked the Plan to waive the copayment for an in-network acute inpatient stay. You say that you saved the 
plan tons of money by only being inpatient for 4 days. You refuse to pay more than $245 for a 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 $245 
copayment each day for days 1 to 8 for Medicare-covered hospital care each time you are admitted for inpatient 
hospital care.  
 You have been asked to pay a $980 total copayment for an in-network acute inpatient 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. Therefore, we decided that the Plan does not have to waive the copayment for 
an in-network acute inpatient stay June 8, 2023, to June 12, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for an inflectra injection provided on July 20, 
2023. 
 
You asked the Plan to reduce the coinsurance for an inflectra injection. You say that you do not understand 
why the cost sharing increased. 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 in-network Part B drugs obtained in a providers office or outpatient setting. 
 
You have been asked to pay 20% coinsurance for an inflectra injection. This item/service falls within the in-network Part B drugs obtained in a providers office or outpatient setting 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 you owe is $541.52 
($2707.60 allowed amount x 20% = $541.52). Therefore, we decided that the Plan does not have to reduce the 
coinsurance for an inflectra injection provided on July 20, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay on July 6, 2023 to 
July 22, 2023 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that since you had already 
spent 16 days in the hospital prior to your rehabilitation admission, you should not be charged a copayment for 
your rehabilitation. 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 $390 
copayment for each day in the hospital for the first 5 days ($390 x 5 = $1,950) for inpatient hospital care.  
 
 You have been asked to pay a $390 copayment for each day in the hospital for the first 5 days ($390 x 5 = 
$1,950) for 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. Therefore, we decided that 
the Plan does not have to waive the copayment for an inpatient hospital stay on July 6, 2023 to July 22, 2023
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hospital observation services, and the 
ambulance services provided by an in-network provider on July 17, 2023, and July 18, 2023. 
 
You asked the Plan to waive the copayment for the observation and ambulance services. You say that you 
believe that these services are 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 $290 
copayment per date of service for in and out-of-network emergency and non-emergency ambulance services, 
and a $245 copayment for in and out-of-network outpatient hospital observation services. 
 
You have been asked to pay a $290 copayment for the ambulance services. These items/services fall within the 
ambulance services benefit category. You have also been asked to pay a $245 copayment for the observation 
services. These items/services fall within the outpatient hospital observation 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 hospital observation services, and the ambulance services 
provided by an in-network provider on July 17, 2023, and July 18, 2023.