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

 
We decided that the Plan does not have to waive the deductible for a CT scan and to waive the copayment for 
laboratory services provided on November 11, 2019. 
 
You asked the Plan to waive the deductible for a CT scan and to waive the copayment for laboratory services. 
You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct amount. 
 
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 $750 deductible. Your contract with the Plan also clearly says that 
you must pay a $10 copayment for lab services. 
 
You received a CT scan on November 11, 2019. The record shows that you had only paid $526.84 toward the 
$750 deductible. Therefore, you are responsible to pay the allowed amount of $164.08.  
 
You received laboratory services on November 11, 2019. Therefore, you are responsible to pay the $10 
copayment.  
 
The total amount you owe is: $174.08.   
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
hospital services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible for outpatient hospital services. This cost sharing is a contractual obligation that had not been met at 
 
 
the time a CT scan and laboratory services were received on November 11, 2019. Therefore, we decided that 
the Plan does not have to waive the deductible for a CT scan and to waive the copayment for laboratory 
services provided on November 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services for the 
enrollee. 
 
You asked the Plan to pre-approve a MRI. You say that the MRI is needed in order to determine if corrosion is 
a possibility due to a left hip replacement the enrollee has had in the past. The Plan denied your request. The 
Plan says that the clinical information does not show that the enrollee needs imaging for new or changed 
musculoskeletal signs and/or symptoms as the result of a clinical re-evaluation having shown a failure of 
significant clinical improvement following a recent six week trial of provider-directed conservative 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 a MRI. Our reviewer says that a MRI is 
not medically reasonable and necessary for the enrollee in this case. This enrollee presents with apparent new 
onset of left hip pain. Past surgical history is positive for left total hip arthroplasty and revision left total hip 
arthroplasty. Clinical exam findings are limited to tenderness to palpation. There is full left hip range of 
motion, no pain with range of motion and full strength. There is no clear discussion of recent radiographs that 
are non-diagnostic to support the medical necessity of additional imaging at this time. Previous radiographs 
revealed stable left hip components. Detailed evidence of a recent, reasonable and/or comprehensive non-
operative treatment protocol trial and failure has not been submitted. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for a MRI 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve magnetic resonance imaging (MRI) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on July 1, 2020. 
 
You asked the Plan to pay for the dental service. You say that you cannot tolerate bitewing x-rays. You say that 
you have a bad gag reflex. You say that the panoramic x-ray should be covered. The Plan denied your request. 
The Plan says panoramic x-ray is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
panoramic x-ray (D0330) provided on July 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a group 2 pressure reducing mattress provided on July 16, 
2020. 
 
You asked the Plan to pay for group 2 pressure reducing mattress. You say that the enrollee has 2 pressure 
ulcers and requires a pressure reducing mattress to prevent future ulcers. The Plan denied your request. The 
Plan says the denial of payment for this item is correct, because the enrollee does not meet the Medicare 
criteria for a group 2 pressure reducing surface.  
 
 
 
The Plan follows Medicare rules. Medicare rules say that a group 2 pressure reducing support surface is only 
covered when at least one of the criteria listed in the previous section has been met.  
 
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 group 2 pressure reducing mattress. Our 
reviewer says that this group 2 pressure reducing surface does not meet the Medicare criteria for coverage. Our 
physician reviewer found the documentation does not support that the enrollee has multiple stage II pressure 
ulcers located on the trunk or pelvis, large or multiple stage III or IV pressure ulcers on the trunk or pelvis, or a 
myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of group 2 pressure reducing mattress have not been met. Therefore, we decided 
that the Plan does not have to pay for a group 2 pressure reducing mattress provided on July 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ambulance services and the emergency 
room (ER) visit you received on July 10, 2020. 
 
You asked the Plan to waive the copayments for the ambulance services and the ER visit. You say that you 
cannot afford these copayments. The Plan denied your request. The Plan says you were charged these 
copayments correctly.  The Plan says that for the ambulance services, the allowed amount for the transport 
($370) is less than your copayment obligation, so you are responsible for the full amount. 
 
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 $395 
copayment for ambulance services and a $90 copayment for ER services.  
 
You have been asked to pay $370 for the ambulance services and a $90 copayment for the ER visit. 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 copayments for ambulance services and the emergency room (ER) visit you 
received on July 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ConfirmMDx genetic testing provided on February 5, 
2020. 
 
 
 
You asked the Plan to pay for the ConfirmMDx genetic testing. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services rendered were not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that ConfirmMDx genetic testing is only covered for 
certain indications. 
 
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 ConfirmMDx genetic testing. Our 
reviewer says that the documentation does not support that the services rendered were medically reasonable or 
necessary. Our physician reviewer found the enrollee a slowly rising Prostate Specific Antigen (PSA). Prostate 
biopsies were negative in 2001 and 2017. An MRI fusion prostate biopsy was performed on February 5, 2020. 
The documentation does not support that the enrollee had a previous cancer-negative prostate biopsy within 24 
months. Therefore, the enrollee did not meet criteria for the services rendered. 
 
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 ConfirmMDx genetic testing have not been met. Therefore, we decided that 
the Plan does not have to pay for the ConfirmMDx genetic testing provided on February 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Flector patches. 
 
You asked the Plan to pre-approve Flector. You say that the enrollee has had a meaningful reduction in her 
pain following application. The Plan denied your request. The Plan says the service is not covered under the 
Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Flector patches.  
 
Benefits for Flector may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services coded 01992 provided on February 4, 
2020. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 01992 is anesthesia for diagnostic or therapeutic nerve 
blocks and injections (when block or injection is performed by a different physician or other qualified health 
care professional); prone position. 
 
We find that CPT code 01992 is not supported in the medical record. Specifically, the documentation shows 
that this code was submitted with modifier AA, QZ, and QS. This indicates that anesthesia services were 
performed by anesthesiologist, while modifier QZ indicates a CRNA service without direction by a physician. 
Only one of the billed modifiers would be appropriate with supporting documentation. Therefore, the billed 
code, modifiers and units cannot be supported. Based on this information, we decided that Medicare rules for 
coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay 
for the anesthesia services coded 01992 provided on February 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on April 13, 2020, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that these services were medically necessary. The Plan 
denied your request. The Plan says there are in-network providers available for these services. 
 
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 has network providers 
available who can provide 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 April 13, 2020, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the angioplasty provided on July 16, 2020 
and the office visit provided on August 28, 2020. 
 
You asked the Plan to waive the copayment for the angioplasty and office visit. You say that you were 
informed the copayment for surgery covered anything connected to the operation. You say that the charges 
shouldn't be separated. The Plan denied your request. The Plan says the copayments applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment for each Medicare-covered outpatient surgery service from an in-network provider and a $30 
copayment for each Medicare-covered, in-network specialist visit. 
 
You have been asked to pay a $225 copayment for the angioplasty and a $30 copayment for the office visit. 
The angioplasty falls within the "Outpatient surgery, including services provided at hospital outpatient facilities 
and ambulatory surgical centers" benefit category. The office visit falls 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 copayment for the angioplasty provided on July 16, 2020 and the office 
visit provided on August 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99291) provided on May 22, 2020. 
 
You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the documentation does not include the 
time spent providing this service; therefore, the billed Critical Care Evaluation and Management code cannot 
be verified. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the record. Specifically, the record does not include the 
amount of time spent providing the critical care services. For critical care services, the physician's note must 
document the total time spent providing these services. Based on this information, we decided that Medicare 
rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not 
have to pay for critical care services (99291) provided on May 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99291) provided February 25, 2020 to 
March 1, 2020. 
 
You asked the Plan to pay for critical care services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does 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 code 99291 is Critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, no critical care notes were 
provided for the dates of service at issue. The plan made requests for encounter notes that would support the 
CPT code billed, but no documentation was provided. Based on this information, we decided that Medicare 
rules for coverage of critical care services have not been met. Therefore, we decided that the Plan does not have 
to pay for critical care services (99291) provided February 25, 2020 to March 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on July 1, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you have seen this provider for over 30 years. 
You say that you would like to continue to see this provider. The Plan denied your request. The Plan says prior 
authorization was not obtained. The Plan says that these services can be provided in-network. 
 
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 has network providers 
available who can provide 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 physician services provided on July 1, 2019 by an 
out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan. 
 
You asked the Plan to pre-approve Hyalgan. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the enrollee does not meet step therapy criteria. 
 
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 Hyalgan. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has unilateral primary osteoarthritis of the right knee.  
 
 
 
 
 
The documentation supports that the enrollee has tried Orthovisc but does not support that the enrollee has tried 
Monovisc. There is insufficient documentation that the plan's required drug of Monovisc has been tried and 
there is no physician documentation that Monovisc is not medically appropriate for this enrollee. Therefore, the 
enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blepharoplasty services provided on May 20, 2020. 
 
You asked the Plan to pay for the blepharoplasty services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 15823 is 1. You billed 2 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of the blepharoplasty services have not been met. 
Therefore, we decided that the Plan does not have to pay for the blepharoplasty services provided on May 20, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle foot orthoses, pneumatic compression device, 
gradient compression sleeve, alcohol wipes, neuromuscular stimulator and electrical stimulator supplies 
provided to the enrollee on March 9, 2020. 
 
You asked the Plan to pay for these services. You say that these items were medically necessary. The Plan 
denied your request. The Plan says that these items are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 

This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the ankle foot orthoses, 
pneumatic compression device, gradient compression sleeve, alcohol wipes, neuromuscular stimulator and 
electrical stimulator supplies provided to the enrollee on March 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment provided on March 9, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for durable medical equipment. You say that you could not get this equipment 
anywhere else. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 has network providers 
available who can provide 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 durable medical equipment provided on March 9, 
2020 by an out of network (OON) provider.