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

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has diagnoses of multiple 
sclerosis, diabetes, and anemia of chronic kidney disease. He does not receive dialysis treatment. He has 
tiredness and fatigue. The use of Aranesp in patients with renal disease not on dialysis is not supported by the 
Medicare-approved compendia. The services are not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Aranesp.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspiration. 
 
You asked the Plan to pre-approve bone marrow aspiration. 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 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 bone marrow aspiration. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspiration remains experimental. More research is needed to show 
safety and efficacy. It is not the gold standard for spine fusion at this time. Therefore, the enrollee does not 
meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspiration have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspiration.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Superion 
Vertiflex procedure). 
 
You asked the Plan to pre-approve Vertiflex. You say that this procedure would provide significant clinical and 
quality of life benefits for the enrollee. The Plan denied your request. The Plan says the denial of authorization 
for this service is correct, because Vertiflex is considered experimental/investigational. 
 
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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is a lack of large volume, long-term peer-reviewed outcome studies to support the use of 
Vertiflex for the enrollee's medical condition. There is evidence of instability on flexion and extension. 
Superion indirect lumbar decompression would not be considered the standard of care for the enrollee's 
condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve insertion of an interspinous spacer device (Superion Vertiflex procedure).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint
nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint( CPT Code 64635).
You asked the Plan to pre-approve the services. You say that the service is medically necessary. The Plan
denied your request. The Plan says the service is not necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer
found the request exceeds utilization limits. Most successful RFA treatments last more than 6 months with an
average of 18 months being more common. The requested procedures are deemed 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance
(fluoroscopy or CT); lumbar or sacral, single facet joint( CPT Code 64635).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist visits provided on January 31, 
2020 and March 2, 2020. 
 
You asked the Plan to waive the copayments for specialist visits. You say that you feel that the primary care 
provider (PCP) copayment should apply instead. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for specialist visits.  
 
The record shows that you received specialist visits on January 31, 2020 and March 2, 2020. Therefore, you are 
responsible to pay a $45 copayment per each visit. The total amount you owe is: $90.  
 
You have been asked to pay the total copayment amount of $90 for specialist visits. Specialist visits fall within 
the physician/practitioner services, including doctor?s office visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayments for specialist visits provided on January 31, 2020 and March 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on May 19, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the services 
were obtained out-of-network and were not authorized. 
 
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 May 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Genetic GCx testing rendered on September 9, 2019. 
 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the Genetic GCx testing 
rendered on September 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the nerve conduction study (95911) and the 
office visit (99214) provided on January 8, 2020 and January 13, 2020. 
 
You asked the Plan to waive the copayment for these services. 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). Your contract with the Plan clearly says that enrollees must pay a 
$10 copayment per day for Medicare-covered tests. Additionally, enrollees must pay a $45 copayment for each 
covered visit or consultation in an outpatient location with a specialist.  
 
You have been asked to pay a $55 copayment ($10 + $45) for the Medicare-covered test and the specialist 
office visit provided. 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 nerve conduction study 
(95911) and the office visit (99214) provided on January 8, 2020 and January 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate (conscious) sedation (99152) provided March 4, 
2020. 
 
You asked the Plan to pay for moderate (conscious) sedation. You say that you are sending appeal for codes 
33990, 99291, 99152, 99153. Please reconsider and process the claim. The Plan denied your request. The Plan 
says the records do not corroborate the services and confirm Medicare coverage has been met. 
 
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 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15minutes of intra-service time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the documentation submitted 
did not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level 
of consciousness and physiological status. Of note, an independent trained observer is someone other than the 
physician performing the services. Based on this information, we decided that Medicare rules for coverage of 
moderate (conscious) sedation have not been met. Therefore, we decided that the Plan does not have to pay for 
moderate (conscious) sedation (99152) provided March 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Gym membership fees from January 1, 2019 to March 31, 
2019. 
 
You asked the Plan to pay for the gym membership fees. You say that 3 months of your gym reimbursement 
was denied because they exceeded a one year limitation. Each year you submit documentation for the entire 
year. No one has ever notified you about a statute of limitations. The Plan denied your request. The Plan says 
these services were past the 12 month filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the gym membership fees was not filed until April 23, 2020. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for Gym membership fees from January 1, 2019 to March 31, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on April 10, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. 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 April 10, 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 provided by you on April 
10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided on February 26, 
2020. 
 
You asked the Plan to pay for a wrist-hand orthosis. You say that this was medically necessary. The Plan 
denied your request. The Plan says this was prescribed following an unsolicited outreach call. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a wrist-hand orthosis 
(L3916) provided on February 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation and extraction 
provided on April 6, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and extraction. You say that these 
were emergency services. You also say that because you are a member, you would like to be reimbursed the 
annual $550 that the Plan offers. The Plan denied your request. The Plan says the treating provider opted out of 
Medicare effective July 11, 2012 to July 11, 2020. The Plan also says that they will not reimburse for charges 
incurred by Medicare opt out providers. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the problem focused limited oral evaluation and extraction provided on April 6, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound of extracranial arteries 
(93880) performed on June 4, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound of extracranial arteries. You say that it would 
help Plan members if test copayments and hospital stays were lowered. 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 you must pay a $100 
copayment for each Medicare-covered diagnostic procedure and test in an outpatient hospital facility.  
 
You have been asked to pay a $100 copayment for an ultrasound of extracranial arteries. An ultrasound of 
extracranial arteries 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 of extracranial arteries (93880) 
performed on June 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy services coded S9501 provided on 
January 19, 2020 and January 20, 2020. 
 
You asked the Plan to pay for the home infusion therapy services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not payable. 
 
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 S9501 is not supported in the medical record. Specifically, code S9501 has a status 
code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another 
code for reporting of and payment of these services. Based on this information, we decided that Medicare rules 
for coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does 
not have to pay for the home infusion therapy services coded S9501 provided on January 19, 2020 and January 
20, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on 
March 3, 2020. 
 
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you were told that you 
would only owe a $325 copayment. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You received a Medicare Part B drug on March 3, 2020. The allowed amount is $1,224 and 20% of that is 
$244.80.  
 
You have been asked to pay the total coinsurance amount of $244.80 for a Medicare Part B drug. A Medicare 
Part B drug 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 a Medicare Part B drug provided on March 3, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for profile testing provided on July 7, 2019. 
 
You asked the Plan to pay for genetic testing. You say that this testing was ordered by the enrollee's in-network 
treating physician and there is no in-network laboratory that offers the same type of testing. The Plan denied 
your request. The Plan says that the denial of payment for this testing is correct, because these tests are 
experimental/investigational and were not medically necessary. 
 
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. 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 has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-
of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this 
testing would not be covered. Without this information, we cannot determine whether the lab order made 
constituted plan-directed care. Therefore, the Plan did not show that its decision to deny payment for these tests 
is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for 
profile testing provided on July 7, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on 
May 21, 2020. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you were taken to the ER against 
your will and you were potentially exposed to the Coronavirus. You also stated that you cannot afford this 
copayment. 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 $90 
copayment for emergency room services.  
 
You have been asked to pay a $90 copayment for the ER visit. This cost sharing applies regardless of the 
reason for the ER visit. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for the emergency room (ER) visit 
you had on May 21, 2020.