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

We decided that the Plan does not have to pay for lab services provided to the enrollee on June 4, 2020 and 
billed under code 81479. 
 
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 it was determined that the enrollee has a primary insurer. Outbound calls were placed to 
the primary where it was confirmed that they have yet to receive a claim from the provider for processing. The 
provider will need to submit a claim to the enrollee's primary insurer in order to have a primary remit 
generated before this Plan can make payments, if any. An additional outbound call was made to the providers 
office to advise that a claim would need to be submitted to the primary insurer.  
 
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. The Plan has met its obligation with 
regards to coordination of benefits. Specifically, the Plan has notified the provider of the enrollee's primary 
insurer and the steps needed to be taken to file a correct claim. As the secondary insurer, the Plan cannot be 
held responsible for this service until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for lab services provided to the enrollee on June 4, 2020 and billed 
under code 81479.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the remote evaluations of defibrillator 
(93295) provided on May 2, 2020. 
 
You asked the Plan to waive the copayment for the remote evaluations of defibrillator. You say that you do not 
agree with the specialist copayment. The Plan denied your request. The Plan says the copayment applied 
correctly in this case. 
 
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 $30 
copayment for non-radiological diagnostic services.  
 
You have been asked to pay a $30 copayment for the remote evaluations of defibrillator. This service falls 
within the non-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 the remote evaluations of defibrillator (93295) provided on May 2, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay forthe ambulance mileage billed for date of service June 20, 2020 with code A0425.You asked the Plan to pay forthe ambulance mileage. You say that this should be paid.The Plandenied your request. The Plan says that the documentation submitted showed that the correct place of service was 41 and payment was approved for code A0427. However, the edit was appropriately invoked for A0425.The Plan must follow Medicare rules. Medicare rules say that ambulance payment is made on two-lineitems one for the base rate and one for mileage. The Plan approved to pay the base rate but provided no cogent rationale to support continuing non-payment for the mileage billed with code A0425.Therefore, we decided that the Plan has to pay forthe ambulance mileage billed for date of service June 20, 2020 with code A0425.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 toopen the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for destruction of lesions (17004) performed. 
 
You asked the Plan to pay for the procedure. You say that these services were medically necessary. The Plan 
denied your request. The Plan says services billed were not supported by the records 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. 
 
In this case, the CPT Code Manual definition of code 17004 is Destruction (eg, laser surgery, electrosurgery, 
cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses), 15 or more 
lesions. 
 
We find that CPT code 17004 is not supported in the medical record. Specifically, insufficient medical records 
were provided to support the billed services. The plan made requests for additional records and none were 
provided. Based on this information, we decided that Medicare rules for coverage of the procedure have not 
been met. Therefore, we decided that the Plan does not have to pay for destruction of lesions (17004) 
performed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prostate specific antigen (PSA) testing rendered on 
January 28, 2020. 
 
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 testing is not covered. 
 
The Plan must follow Medicare rules. The rules say that generally, for patients with lower urinary tract signs or 
symptoms, the test is performed only once per year unless there is a change in the patient's medical condition. 
 
We looked at the file and Medicare rules. The file shows that the testing was performed with a billed diagnosis 
of mixed hyperlipidemia and not for lower urinary tract signs or symptoms. Based on this information, we 
decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the 
Plan does not have to pay for the prostate specific antigen (PSA) testing rendered on January 28, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a vertebral corpectomy (63090) provided. 
 
You asked the Plan to pay for a vertebral corpectomy. You say that this code is documented in the records. The 
Plan denied your request. The Plan says that this code is 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 63090 is vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or 
retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, 
lumbar, or sacral; single segment. 
 
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 a vertebral corpectomy. Our reviewers says 
that the billing of this code is supported in the records. Our physician reviewer found the operative report 
documents that through a retroperitoneum approach, a partial corpectomy at the L3 vertebral body was 
performed.  The inferior aspect of vertebral body was removed, and disk space was evacuated completely and 
filled with allograft and partial corpectomy. 
 
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 vertebral corpectomy have been met. Therefore, we decided that the Plan has 
to pay for a vertebral corpectomy (63090) provided.  
 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a vitamin assay provided to the enrollee on December 23, 
2019. 
 
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 screening assays are not covered by Medicare. 
 
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 test at issue in this appeal 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 a vitamin assay provided to the enrollee on December 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the depression screening you received on May 22, 2020. 
 
You asked the Plan to pay for the screening. You say that this should be covered. The Plan denied your request. 
The Plan says this is only covered once per year. 
 
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 $0 
copayment for one screening for depression per year.  
 
Review of the file shows that you had a depression screening on May 22, 2020. The records also show that you 
had a covered depression screening on February 4, 2020. This service is only covered once per year, which 
means that the requested screening exceeds the benefit limit. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay 
for the depression screening you received on May 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo (J9299). 
 
You asked the Plan to pre-approve Opdivo. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not supported for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Opdivo. Our reviewer says that the 
requested drug is not supported in this case. Our physician reviewer found the submitted medical records do 
not show that a biopsy has been performed. Without a tissue diagnosis the use of Opdivo is not indicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
 
 
Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Opdivo (J9299).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on June 
21, 2020, to June 24, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you disagree with the 
copayment as charged. The Plan denied your request. The Plan says the copayment applied correctly in this 
case. 
 
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 inpatient hospital care for days 1-7 per admission for inpatient hospital care.  
 
You have been asked to pay a $225 copayment for inpatient hospital care for days 1-7 per admission for the 
inpatient hospital stay. The service provided 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 the inpatient hospital stay provided on June 21, 2020, to 
June 24, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea posterior interspinous spacer procedure.You asked the Plan to pre-approvea posterior interspinous spacer procedure. You say that you would like reconsideration because the enrollee clearly meets the commonly accepted medical criteria supporting surgical intervention.The Plan denied your request. The Plan says medical studies have not proven that the procedure being requested is helpful for treatment of the enrollee's health problem.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 a posterior interspinous spacer procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental and more research is needed to show its safety and efficacy.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 posterior interspinous spacer procedure. have not been met.Therefore, we decided that the Plan does not have to pre-approvea posterior interspinous spacer procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee 
and billed under codes 81162, 81201, 8120381242, 81292, 8129481295, 81297, 8129881300, 81317, 81319, 
81321, 81323, and 81404. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says this claim cannot be paid due to errors with the Place of Service codes and the specimen 
type collected reported in the medical records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. A claim will automatically deny for discrepancies 
with the Place of Service code and a discrepancy between a code billed and the type of specimen that was 
collected if they are not compatible per Medicare billing criteria. The claim submitted has both of those types 
of errors. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee and 
billed under codes 81162, 81201, 8120381242, 81292, 8129481295, 81297, 
8129881300, 81317, 81319, 81321, 81323, and 81404.
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. 
 
You asked the Plan to pay for these services. 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.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic mammogram rendered on July 9, 2020. 
 
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 are not covered. 
 
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 77065 is 2. You billed 2 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the diagnostic mammogram rendered on July 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intermittent limb compression device. 
 
You asked the Plan to pay for the intermittent limb compression device. You say that the claim should be paid. 
The Plan denied your request. The Plan says the documentation submitted did not include an itemized 
shipping/billing invoice to indicate the specific supplies, or proof of delivery for the billed date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery and relevant medical records which support medical 
necessity for the supplies provided in this case. The documentation submitted did not include an itemized 
shipping/billing invoice to indicate the specific supplies, or proof of delivery for the billed date of service. 
Therefore the billed code cannot be verified.  The record shows that the Plan made several attempts to obtain 
the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for an 
intermittent limb compression device.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the lab services provided on August 2, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that this is not a 
covered service. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the lab services by a contract provider. The file does not show that the Plan provided notice 
that the lab services would not be covered. Under Medicare rules, this means the lab services is considered 
approved by the Plan. You received the services with the reasonable expectation that they would be covered 
under your plan. Therefore, we decided that the Plan has to pay for the lab services provided on August 2, 
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.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Multaq. 
 
You asked the Plan to pre-approve Multaq. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Multaq.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen equipment provided. 
 
You asked the Plan to pay for oxygen equipment. You say that it will cost you and the Plan a lot more. The 
Plan denied your request. The Plan says Medicare and the Plan will not cover the cost of purchasing a device. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay for oxygen equipment 
that is purchased. 
 
We looked at the file and Medicare Rules. Based on this information, we decided that Medicare rules for 
coverage of the CPAP machine have not been met. Specifically, this item was purchased. Medicare does not 
cover this item when it is purchased. Therefore, we decided that the Plan does not have to pay for oxygen 
equipment provided.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Superion interspinous spacer (22869). 
 
You asked the Plan to pre-approve a Superion interspinous spacer. 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 a Superion interspinous spacer. 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. More research is needed to show safety 
and efficacy. 
 
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 Superion interspinous spacer have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Superion interspinous spacer (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 11, 2019 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 December 11, 
2019 by an out of network (OON) provider.