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

 
We decided that the Plan does not have to pre-approve DPYD (Dihydropyrimidine Dehydrogenase) gene 
analysis identified with code 81232. 
 
You asked the Plan to pre-approve DPYD gene analysis. 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 a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing for DPYD is non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of DPYD gene analysis have not been met. Therefore, we decided that the Plan does not have to pre-
approve DPYD (Dihydropyrimidine Dehydrogenase) gene analysis identified with code 81232.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve physician services. You say that you would like approval for these services. 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physician services to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower extremity arterial doppler studies (93923). 
 
You asked the Plan to pre-approve lower extremity arterial doppler studies. You say that this is necessary to 
follow up the previous study. The Plan denied your request. The Plan says this is not indicated at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that non-invasive studies of the arterial system are to 
be utilized when invasive correction is contemplated or severity of findings dictate non-invasive study follow-
up, but not for following non-invasive medical treatment regimens. Screening of the asymptomatic patient is 
not covered by Medicare. 
 
We looked at the file and Medicare rules. The record indicates that this study was requested to follow up a 
previous study and non-invasive treatment. There are no medical records since the treatment plan was 
established indicating medical necessity for a repeat study. Based on this information, we decided that 
Medicare rules for coverage of lower extremity arterial doppler studies have not been met. Therefore, we 
decided that the Plan does not have to pre-approve lower extremity arterial doppler studies (93923).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sclerotherapy 
 
You asked the Plan to pre-approve sclerotherapy (36471). You say that the enrollee needs sclerotherapy. The 
Plan denied your request. The Plan says criteria is not met for sclerotherapy. 
 
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. There is no record of conservative therapy or symptoms of 
significantly diseased vessels of the lower extremities. Based on this information, we decided that Medicare 
rules for coverage of sclerotherapy (36471) have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sclerotherapy
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrical device to document cardiac arrhythmia (0297T) 
provided to the enrollee on March 4, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says There was no report of symptoms, evaluation of the response to antiarrhythmic drug 
therapy, evaluation of a myocardial infarction (MI) survivor with an ejection fraction of 40% or less, 
assessment of coronary artery disease with active symptoms, need to correlate chest pain with ST-segment 
changes, other acute and subacute forms of ischemic heart disease, or need to detect arrhythmias post ablation 
procedures.  Further, after more than three attempts to obtain information, none was received as of this time.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes and provide medical records to support the services 
billed. In this case, the records provided do not demonstrate the enrollee met the required criteria for coverage 
of this device. Medicare rules for coverage of this service have not been met. Therefore, we decided that the 
Plan does not have to pay for an electrical device to document cardiac arrhythmia (0297T) provided to the 
enrollee on March 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve block (64624). 
 
You asked the Plan to pre-approve genicular nerve block. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found genicular nerve blocks and genicular nerve ablation are considered investigational 
and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the 
following:  degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a 
treatment following knee replacement; or as a treatment for individuals who are not candidates for knee 
replacement surgery. The review has determined that the items/services at issue in this case are not medically 
reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve block (64624).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Truxima (Q5115). 
 
You asked the Plan to pre-approve Truxima. You say that Truxima is medically necessary. The Plan denied 
your request. The Plan says a trial of Rituximab 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 Truxima. Our reviewer says that 
Truxima is not medically necessary. Our physician reviewer found the documentation does not show a trial of 
the plan preferred drug or any reason why 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 Truxima have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Truxima (Q5115).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the outpatient hospital services rendered 
from June 17, 2020 to July 24, 2020. 
 
You asked the Plan to waive the copayments for these services. You say that you disagree with the charges. 
The Plan denied your request. The Plan says the copayments were 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 $150 
copayment for all other services performed at an outpatient hospital facility not otherwise noted.  
 
Review of the file shows that you received wound care services at an outpatient hospital for five dates of 
service from June 17, 2020 to July 24, 2020. You have been asked to pay a $150 copayment per date of service 
for these services, for a total of $750. These services fall within the all other services performed at an outpatient 
hospital facility not otherwise noted 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 copayments for 
the outpatient hospital services rendered from June 17, 2020 to July 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray (73565). 
 
You asked the Plan to pay for an x-ray. You say that this code is supported. The Plan denied your request. The 
Plan says this is not the most appropriate 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 73565 is radiologic examination, knee; both knees, 
standing, anteroposterior. 
 
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 an x-ray. Our reviewer says that this code is 
not supported. Our physician reviewer found when CPT 73565 is reported during the same session as other 
views, the standing views would not be reported as a separate service. They would be included in the total 
number of views obtained during the session.  Therefore, this code should not be reported separately. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an x-ray have not been met. Therefore, we decided that the Plan does not have 
to pay for an x-ray (73565).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient admission and spinal surgery. 
 
You asked the Plan to pre-approve acute inpatient admission and spinal surgery. You say that the services are 
necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that lumbar fusion is covered when specific criteria is 
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 pre-approve acute inpatient admission and spinal 
surgery. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee 
has severe stenosis and kyphosis. This surgery is destabilizing and requires fusion. The laminectomy will 
destabilize the spine. Therefore the fusion is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient admission and spinal surgery have been met. Therefore, we 
decided that the Plan has to pre-approve acute inpatient admission and spinal surgery.  
 
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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a nebulizer provided on May 19, 2020. 
 
You asked the Plan to pay for the nebulizer. You say that you would like reconsideration because the Plan 
advised you to go ahead and purchase the nebulizer at this pharmacy. The Plan denied your request. The Plan 
says that this provider is not eligible for Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items 
or services from either Medicare (in the case of an assigned claim) or a Medicare beneficiary (in the case of an 
unassigned claim), a provider or supplier must be enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the nebulizer have been met. Specifically, Medicare lists this provider as eligible to supply durable 
medical equipment. Therefore, we decided that the Plan has to pay for a nebulizer provided on May 19, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating 
provider on February 2, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you do not agree with these 
charges. 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 $155 
copayment for outpatient diagnostic tests/radiological diagnostic services.  
 
You have been asked to pay $65.42 which is less than your copayment amount of $155 for an ultrasound. An 
ultrasound falls within the outpatient diagnostic tests/radiological diagnostic services benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an ultrasound provided by a participating provider on 
February 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider on July 14, 2020, to July 18, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were in the hospital 
for two extra days. 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 $195 
copayment per day for days 1-8. There is a $0 copayment for additional days for inpatient hospital care.  
 
You have been asked to pay a $195 copayment per day for days 1-4 for an inpatient hospital stay. The total 
amount you are being asked to pay is $780 ($195 x 4 days = $780). An inpatient hospital stay 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 provided by a participating provider on July 14, 2020, to July 18, 2020.  
 
We note your complaint about waiting for a referral for two days. Your complaint is a grievance that must be 
answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a 
participating provider on August 13, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you thought that you would 
save money getting both procedures done at the same time. 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 $325 
copayment for outpatient surgery.  
 
You have been asked to pay a $325 copayment for an outpatient surgery. The correct copayment has been 
applied to the services provided. An outpatient surgery falls within the outpatient surgery 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 August 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an Eylea injection (J0178) received on 
June 1, 2020. 
 
You asked the Plan to waive the coinsurance for an Eylea injection. You say that you have not been paying this 
charge due to thinking it was not your responsibility. The Plan denied your request. The Plan says the correct 
coinsurance 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 you must pay 20% 
coinsurance for Medicare Part B covered drugs.  
 
You have been asked to pay $75.08, or 20% of the Medicare-allowed amount of $375.38, for an Eylea 
injection. An Eylea injection falls within the "Medicare Part B prescription drugs" 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 an Eylea injection (J0178) received on June 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic services provided on June 19, 2020. 
 
You asked the Plan to pay for therapeutic services. You say that you needed these treatments. The Plan denied 
your request. The Plan says the denial of payment for these services is correct, because these services are not 
covered when performed by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for therapeutic services provided on June 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 20, 2020, by an 
OON provider. 
 
You asked the Plan to pay for nursing facility care. You say that you rendered treatment to the enrollee in good 
faith that the service will get reimbursed. The Plan denied your request. The Plan says rules for payment have 
not been met. 
 
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 February 20, 
2020, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
July 17, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 out of network physician 
services provided to the enrollee on July 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the requested services exceed your 
benefit limit. 
 
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. Review of the file shows that you have 
currently used 22 of the plan covered 24 one-way transportation trips. Once you have used your last 2 one-way 
trips, you will have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.