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

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion Indirect Decompression System 
for implantation of Superion spinal spacers. 
 
You asked the Plan to pre-approve the Vertiflex Superion Indirect Decompression System for implantation of 
Superion spinal spacers. You say that the minimally invasive implantation of a posterior interspinous process 
spacer device is the most appropriate treatment for the enrollee. You say that this choice meets the 
requirements as being reasonable and medically necessary. You say that conservative treatments have not be 
effective in adequately addressing the enrollee's clinical symptoms, chronic pain, and loss of functional status. 
You say that the enrollee is not a good candidate for invasive surgical procedures, especially when an FDA-
approved minimally invasive treatment option is available. The Plan denied your request. The Plan says there 
are not enough scientific studies to show that inserting a device to open the narrowed space would be safe and 
effective. 
 
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 Vertiflex Superion Indirect 
Decompression System for implantation of Superion spinal spacers. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the spacer remains experimental for use in spinal surgery. More research is needed to show the safety 
and efficacy of the device. 
 
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 Vertiflex Superion Indirect Decompression System for implantation of 
Superion spinal spacers have not been met. Therefore, we decided that the Plan does not have to pre-approve 
the Vertiflex Superion Indirect Decompression System for implantation of Superion spinal spacers.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for manual therapy (97140) provided from November 20, 2019 
to December 12, 2019. 
 
You asked the Plan to pay for manual therapy. You say that you have been reimbursed for this service is the 
past. The Plan denied your request. The Plan says the facility that provided this service does not include any 
medical providers. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program 
 
We looked at the file and Medicare rules. The provider of this service is not enrolled in the Medicare program. 
Based on this information, we decided that Medicare rules for coverage of manual therapy have not been met. 
Therefore, we decided that the Plan does not have to pay for manual therapy (97140) provided from November 
20, 2019 to December 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 40 additional routine transportation trips (A0100).
You asked the Plan to pre-approve the additional trips. You say that more office visits are needed this year due to complex medical issues and needing to see providers of different specialties. The Plan denied your request. The Plan says this request exceeds the benefit frequency limitation.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 40 additional routine transportation trips (A0100).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing. 
 
You asked the Plan to pre-approve genetic testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that 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 pre-approve genetic testing. Our reviewer says that 
the documentation does not support that the requested genetic testing is medically reasonable or necessary. Our 
physician reviewer found the enrollee has a diagnosis of Other specified diseases of the pancreas. The enrollee 
has intermittent abdominal pain. The enrollee is taking pancreatic enzymes which has resulted in significant 
improvement in stools. Stool elastase is less than 50, which is consistent with severe exocrine pancreatic 
insufficiency, although diarrhea of any etiology can cause a false positive result. The documentation does not 
support that the enrollee has a diagnosis, condition, and/or symptoms that meet the Medicare criteria for 
coverage of genetic testing. The documentation does not support that the enrollee has undergone pedigree 
analysis, genetic counseling, and completion of conventional diagnostic studies. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genetic testing.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound examination provided on 
May 1, 2020. 
 
You asked the Plan to waive the copayment for ultrasound. You say that you believe that this should be 
covered as part of the mammography benefit. The Plan denied your request. The Plan says the copayment 
amount you are being charged is correct. 
 
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 $100 
copayment for ultrasound exam.  
 
You have been asked to pay the allowed amount of $93.54, which is less than the $100 copayment for 
ultrasound. Ultrasound 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. 
Therefore, we decided that the Plan does not have to waive the copayment for an ultrasound examination 
provided on May 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on March 16, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan
requires utilization of network providers when possible and available, and requires authorization for certain
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has
been documented.
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 did not pre-approve the
physician's services. We found no exception that would require the Plan to pay for these services. Therefore,
we decided that the Plan does not have to pay for physician's services provided on March 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for oxygen equipment (E0431, E1390) 
provided September 12, 2019 to October 12, 2019. 
 
You asked the Plan to waive the coinsurance for the oxygen equipment. You say that you stopped using the 
oxygen on October 3, 2019 so the coinsurance should be reduced. The Plan denied your request. The Plan says 
the enrollee is liable for the equipment until the supplier picked it up. 
 
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 Durable Medical Equipment.  
 
You have been asked to pay a 20% coinsurance for the oxygen equipment from the date it was delivered until 
the date it was picked up. The oxygen equipment falls within the Durable Medical Equipment benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for oxygen equipment (E0431, E1390) provided September 12, 
2019 to October 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 23, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior 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 medical services provided on March 23, 2020 
by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that on the date of service you were vomiting 
violently and so your husband called 911 for assistance. You say that the responders came and after checking 
your temperature, they left. You stated that they were with you for no longer than five minutes and they did not 
seem to show any concern about your condition. You say that after they left, you continued to be sick until the 
next day. You stated that you later discovered that one of the side effects of your medication was vomiting. 
You asked the Plan to reconsider their decision and to provide coverage for the services. The Plan denied your 
request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 20, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neurology services (CPT 64581) provided to the enrollee on 
August 6, 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 Current Procedural Terminology (CPT) code 64581 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 64581 is "Incision for implantation of neurostimulator 
electrode array; sacral nerve (transforaminal placement)." 
 
We find that CPT code 64581 is not supported in the medical record. Specifically, the operative note is for a 
different date of service (August 7, 2019) than the billed date of service (August 6, 2019). 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 neurology services (CPT 64581) provided to the enrollee on 
August 6, 2019.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ER visit provided on January 21, 2020. 
 
You asked the Plan to pay for the ER visit. You say that the claim should be paid in full or under the terms of 
the contract. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ER visit provided on January 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a telemedicine specialist visit provided on March 17, 2020.
You asked the Plan to waive the copayment for a telemedicine specialist visit. You say that you did not have a visit. The Plan denied your request. The Plan says services were provided over the phone. The Plan says that 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 $40 copayment for physician/practitioner services/Select/specialist. You have been asked to pay a $40 copayment for a telemedicine specialist visit. a telemedicine specialist visit falls within the physician/practitioner services/Select/specialist 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 telemedicine specialist visit provided on March 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home International Normalized Ratio (INR) testing materials 
(G0249) billed on February 14, 2020 and February 22, 2020. 
 
You asked the Plan to pay for home INR testing materials. You say that this was billed correctly. The Plan 
denied your request. The Plan says this exceeds the frequency limitations for this code. 
 
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 G0249 is provision of test materials and equipment for 
home INR monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous 
thromboembolism who meets Medicare coverage criteria; includes: provision of materials for use in the home 
and reporting of test results to physician; testing not occurring more frequently than once a week; testing 
materials, billing units of service include 4 tests. 
 
We find that CPT code G0249 is not supported in the medical record. Specifically, testing should not be 
performed more than once a week and each unit of the billed code includes four tests. The record shows that 
this code was billed and paid on January 31, 2020. The units billed on February 14, 2020 and February 22, 
2020 exceed the frequency limitations. Based on this information, we decided that Medicare rules for coverage 
of home INR testing materials have not been met. Therefore, we decided that the Plan does not have to pay for 
home International Normalized Ratio (INR) testing materials (G0249) billed on February 14, 2020 and 
February 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 17, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says the enrollee's
plan requires utilization of network providers, and authorization for certain 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 services at issue in this appeal. The Plan did not pre-approve the services at
issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided
that the Plan does not have to pay for the medical services provided on September 17, 2019 by an out of
network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the advanced imaging and Part B drug 
services rendered on February 20, 2020. 
 
You asked the Plan to waive the cost sharing for these services. You say that you were not aware you would 
have a copayment. The Plan denied your request. The Plan says the cost sharing was 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 advanced imaging service (not including x-rays) and 20% of the plan-
allowed amount for Medicare Part B-covered drugs. 
 
Review of the file shows that you received myocardial perfusion imaging (MPI) on February 20, 2020. You 
have been asked to pay a $225 copayment for these services. These services fall within the Medicare-covered 
advanced imaging service (not including x-rays) benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan.  
 
The file shows that you received a drug injection on February 20, 2020. You have been asked to pay 20% of 
the total cost for these services, for a total of $1.18. These services fall within the Medicare Part B-covered 
drugs benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. 
 
The total amount you have been asked to pay for these services is $226.18. 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 advanced imaging and Part B drug services rendered on February 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious agent testing (87801,87798, and 87481) provided 
to the enrollee on November 12, 2019. 
 
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your 
request. The Plan says the records provided do not determine this testing was medically necessary. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. The testing at issue was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for infectious agent testing (87801,87798, and 87481) provided to the enrollee on November 12, 2019.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing services (CPT 80307 and HCPCS G0483) provided to the 
enrollee on June 24, 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 that 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 80307: 
 
Drug test(s), presumptive, any number of drug classes, qualitative; any number of devices or procedures, by 
instrument chemistry and analyzers (e.g.,  utilizing immunoassay [EIA, ELISA, EMIT, FPIA, IA, KIMS, 
RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, 
(DAT, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation 
when performed, per date of service 
 
HCPCS G0483: 
 
Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and 
distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms 
(any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, 
elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally 
recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in 
signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., 
to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes 
specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed 
 
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 services. Our reviewers says that the 
services at issue in this case were supported by the medical records. Our physician reviewer found the 
laboratory submitted a valid/signed physician laboratory requisition form and lab results. The review has 
determined that the records support the denied codes. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
drug testing services (CPT 80307 and HCPCS G0483) provided to the enrollee on June 24, 2019.  
 
 
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.