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

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy (45385) 
performed on June 24, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you should not be 
responsible for this copayment because there was nothing found during the procedure. The Plan denied your 
request. The Plan says the correct copayment was applied. 
 
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 a screening 
colonoscopy can become a diagnostic colonoscopy when the screening colonoscopy results in the biopsy or 
removal of a lesion or growth. Your contract also says that you must pay a $150 copayment for Medicare-
covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility.  
 
In this case, medical records supplied by the provider document that your colonoscopy was a diagnostic 
colonoscopy. You have been asked to pay a $150 copayment for the diagnostic colonoscopy. A diagnostic 
colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities 
and ambulatory surgical centers" 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 
diagnostic colonoscopy (45385) performed on June 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vraylar, 6mg capsule. 
 
You asked the Plan to pre-approve Vraylar. You say that this medication was added to your regimen given at 
the hospital. You say that you were feeling that the hospital medications did not adequately help your moods. 
You say that you have been doing well on the medication since early 2020. You also say that the failure to 
prescribe may result in symptoms. The Plan denied your request. The Plan says the requested drug is 
considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D 
prescription drug plan. The Plan says the requested drug is not covered under Medicare Part B. 
 
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 Vraylar, 6mg capsule.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test (G0480) provided on June 11, 2020, by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the drug test. You say that you would like this claim reprocessed and approved 
for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the facility 
or the provider; therefore, payment has been correctly denied. 
 
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 the drug test (G0480) provided on June 11, 2020, 
by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your 
request. The Plan says a trial of Zoledronic Acid is required before alternatives can be considered. 
 
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 Prolia. Our reviewer says that Prolia is 
not medically necessary. Our physician reviewer found there was no trial of the plan preferred drug or any 
records that show the plan preferred drug would be unsafe or ineffective 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve RFA. You say that you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says the services are not covered at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare says a maximum of five (5) facet joint injection sessions 
inclusive of medial branch blocks, intra-articular injections, facet cyst rupture and RF ablations may be 
performed per rolling 12-month year in the cervical/thoracic spine and five (5) in the lumbar spine. The file 
shows that the enrollee has received 5 treatments this year. Based on this information, we decided that 
Medicare rules for coverage of RFA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214), destruction of skin growth (17000) 
and destruction of 2-14 skin growths (178003) provided on July 28, 2020 by an out of network (OON) 
provider. 
 
You asked the Plan to pay for office visit and destruction of skin growths. You say that this service was a 
continuation of a referral from you primary care physician. The Plan denied your request. The Plan says prior 
authorization must be obtained for non-emergent services rendered by an out-of-network provider. The 
previous authorization expired prior to this service and therefore, needed a new authorization. 
 
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 the office visit (99214), destruction of skin growth 
(17000) and destruction of 2-14 skin growths (178003) provided on July 28, 2020 by an out of network (OON) 
provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a Superion spacer device (22870, 22869). 
 
You asked the Plan to pre-approve the Superion spacer device. You say that the service is medically necessary. 
The Plan denied your request. The Plan says that the device at issue is considered investigational. 
 
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. No medical records were provided to the IRE for review. Records were 
requested on October 16, 2020 with no response from the Plan. Therefore, we decided that the Plan has to pre-
approve a Superion spacer device (22870, 22869).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery you had on June 2, 2020. 
 
You asked the Plan to waive the copayment for the outpatient surgery. You say that you can't afford this bill. 
The Plan denied your request. The Plan says you were charged this copayment 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 $200 
copayment for ambulatory surgery visits.  
 
You have been asked to pay a $200 copayment for the outpatient surgery. 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 outpatient surgery you had on June 2, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says you have used all 100 days of SNF care for this 
benefit period. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period. The Plan has covered 
100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forblood tests (80053 and 85025) performed on February 4, 2020, and an A1c level (83036) performed on March 9, 2020.You asked the Plan to waive the copayments forblood tests and an A1c level. You say that both sets of bloodwork were done in-house and not by an outside lab.The Plan denied your request. The Plan says the correct copayments were applied.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 $10 copayment for bloodwork drawn at a physician's office and sent to an independent lab for processing. In this case, the record documents that your bloodwork was not processed at the physician's office. You have been asked to pay a $10 copayment for blood tests and a $9.71 copayment for an A1c level. Blood tests and an A1c level fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay less than or equal to the full 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 forblood tests (80053 and 85025) performed on February 4, 2020, and an A1c level (83036) performed on March 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic radiological tests provided by a 
participating provider on May 20, 2020. 
 
You asked the Plan to waive the copayment for diagnostic radiological tests. You say that you think you are 
being over charged. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 $160 
copayment for outpatient diagnostic tests/radiological tests.  
 
You have been asked to pay a $160 copayment for each diagnostic radiological test. The total amount you are 
being asked to pay is $320 ($160 x 2 tests = $320). Diagnostic radiological tests fall within the outpatient 
diagnostic tests/radiological tests 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 
diagnostic radiological tests provided by a participating provider on May 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 22, 2020. 
 
You asked the Plan to pay for the services. 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. 
 
We find that the requested CPT codes are not supported in the medical record. Specifically, the records 
provided do not show that lab services were performed with blood sampling. The records show that a urine 
specimen was collected. The billed services cannot be verified. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on June 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an abdominal paracentesis (49083) performed April 8, 2020. 
 
You asked the Plan to pay for the abdominal paracentesis. You say that the service was medically necessary. 
The Plan denied your request. The Plan says a correct diagnosis code was not provided. 
 
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 code 49083 is not supported in the medical record. Specifically, there was an invalid primary 
diagnosis code listed. No corrected claim was received. Based on this information, we decided that Medicare 
rules for coverage of the abdominal paracentesis have not been met. Therefore, we decided that the Plan does 
not have to pay for an abdominal paracentesis (49083) performed April 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve multiple power options for a power wheelchair (E2300, 
E2311, E2377, E2313) for the enrollee. 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the accessories. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not support that the requested power options are medically necessary 
for the enrollee in this case. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve multiple power options for a power wheelchair (E2300, E2311, E2377, E2313) for the 
enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a 
participating hospital on May 11, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that these charges do not add 
up. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 $450 
copayment for outpatient surgery/in-network/outpatient hospital.  
 
You have been asked to pay a $450 copayment for an outpatient surgery. The services that were provided were 
considered an outpatient surgery; therefore, the correct copayment has been applied. An outpatient surgery falls 
within the outpatient surgery/in-network/outpatient hospital 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 outpatient surgery provided by a participating provider on May 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance services provided to the enrollee on July 3, 
2019. 
 
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 primary insurance paid for this at a rate greater than the Medicare allowed amount. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has confirmed 
that the primary insurance paid for these services above the Medicare allowed rate. As the secondary insurer, 
the Plan cannot be held responsible for the services until the primary insurer has denied the claim for these 
services. Therefore, we decided that the Plan does not have to pay for air ambulance services provided to the 
enrollee on July 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360? molecular pathology genomic profiling 
provided on May 19, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration because 
this testing is medically necessary. The Plan denied your request. The Plan says there is a more appropriate 
code to describe the services performed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Guardant360 testing have not been met. Specifically, per Medicare's Local Coverage Article: 
Billing and Coding: GUARDANT360 (A58192), this service must be billed with CPT code 81479. 
Therefore, we decided that the Plan does not have to pay for Guardant360 molecular pathology genomic 
profiling provided on May 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional 30 minutes of critical care services (99292) 
provided on April 23, 2019. 
 
You asked the Plan to pay for the additional critical care services. You say that you would like reconsideration 
because this service was reported correctly. The Plan denied your request. The Plan says the documentation 
submitted does not support that an additional 30 minutes of critical care services were rendered. 
 
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 99292 is critical care, evaluation and management of the 
critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for 
primary service). 
 
We find that CPT code 99292 is not supported in the record. Specifically, the record indicates that 40 minutes 
were spent rendering critical care services on the billed date of service. The documentation submitted does not 
support the service billed. Based on this information, we decided that Medicare rules for coverage of the 
additional critical care services. have not been met. Therefore, we decided that the Plan does not have to pay 
for an additional 30 minutes of critical care services (99292) provided on April 23, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
June 29, 2020, through June 30, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that he must pay a 
$300 copayment per admission after the deductible is met for each medically necessary inpatient stay.  
 
The enrollee has been asked to pay a $300 copayment for the inpatient hospital admission provided. This 
means that the enrollee has been asked to pay the correct amount based on his contract with the Plan. This cost 
sharing is a contractual obligation the enrollee agreed to pay when he enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from  
June 29, 2020, through June 30, 2020.