Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Partially Favorable

We decided that the Plan has to reduce the cost-sharing charges for a Medicare Part B drug injection. We 
decided that the Plan does not have to reduce the cost-sharing charges for a Medicare Part B drug injection to 
the amount you requested.  
 
You asked the Plan to reduce the cost-sharing charges for a Medicare Part B drug injection. You say that you 
should only owe a copayment. The Plan says that the claims were processed correctly and you are being 
charged the correct amount. 
 
We decided that the Plan has to reduce the cost-sharing charges for a Medicare Part B drug injection 
from $285.14 to $280.58.  
 
Your contract with the plan says that you must pay 20% coinsurance for Medicare Part B drugs. You cannot be 
asked to pay more than 20% coinsurance for Medicare Part B drugs. Therefore, we decided that the Plan has to 
reduce the cost-sharing charges for a Medicare Part B drug injection from $285.14 to $280.58.  
 
We also decided that the Plan does not have to reduce the cost-sharing charges for a Medicare Part B 
drug injection to the amount you requested.  
 
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 a Medicare Part B drug injection. The allowed amount is $1,402.89 and 20% of that is $280.58. 
Therefore, we decided that the Plan does not have to reduce the cost-sharing charges for a Medicare Part B 
drug injection to the amount you requested.  
 
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 pay for an ultrasound screening for abdominal aortic aneurysms 
(AAA) provided on May 16, 2020. 
 
You asked the Plan to pay for AAA ultrasound screening. You say that this procedure was a follow-up from a 
previously diagnosed potentially serious health concern. The Plan denied your request. The Plan says the denial 
of payment for this service is correct, because this test is covered as a one-time screening and you previously 
had this screening on December 27, 2018. 
 
The Plan must follow Medicare rules. Medicare rules say that an ultrasound screening for AAA is only covered 
once for eligible beneficiaries. 
 
We looked at the file and Medicare rules. You previously received a AAA ultrasound screening on December 
27, 2018; therefore, you were not eligible to receive this test again. Based on this information, we decided that 
Medicare rules for coverage of AAA ultrasound screening have not been met. Therefore, we decided that the 
Plan does not have to pay for an ultrasound screening for abdominal aortic aneurysms (AAA) provided on May 
16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical nutrition therapy provided on August 3, 2020. 
 
You asked the Plan to pay for medical nutrition therapy services. You say that you must have this service to do 
a revision of your lap-band. The Plan denied your request. The Plan says the denial of payment for this service 
is correct, because you do not have a known diagnosis of diabetes or kidney disease. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does 
not have to pay for medical nutrition therapy provided on August 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on June 2, 2020 and 
billed under codes 80157, 80159, 80162, 80173, 80177, and 80201.  
 
You asked the Plan to pay for lab services provided to the enrollee. You say that this claim should be paid. The 
Plan denied your request. The Plan says that for the codes denied, the documentation submitted did not support 
that testing with a serum specimen was performed with blood sampling.  Blood specimen collection is by 
venipuncture; however, the lab requisition states a urine specimen was collected; therefore, the billed service 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, this claim cannot be paid due to an error 
with the type of specimen reported. Medicare billing criteria are not met. Therefore, we decided that the Plan 
does not have to pay for lab services provided to the enrollee on June 2, 2020 and billed under codes 80157, 
80159, 80162, 80173, 80177, and 80201.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the esophagogastroduodenoscopy (43239) provided on June 
1, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for esophagogastroduodenoscopy. You say that prior authorization is not required. 
The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services 
rendered by an out-of-network provider. 
 
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 esophagogastroduodenoscopy (43239) 
provided on June 1, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment (DME) provided on May 12, 
2020. 
 
You asked the Plan to pay for the DME. The Plan denied your request. The Plan says billed services are not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that a description of the item(s) being delivered must 
be documented for coverage of DME.  
 
We looked at the file and Medicare rules. The proof of delivery does not contain an itemized delivery ticket 
with a description of the items being delivered. Based on this information, we decided that Medicare rules for 
coverage of the DME have not been met. Therefore, we decided that the Plan does not have to pay for the 
durable medical equipment (DME) provided on May 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laparoscopy, surgical, gastric restrictive procedure; with
gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less) (CPT Code 43644).

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your
request. The Plan says the services are 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 this patient is a potential candidate for the requested roux-en y gastric bypass given that the patient has
BMI of 38 with HTN but does not meet LCD criteria for failure to document understanding of dietary and
behavioral lifestyle changes that would include both a dietary and psychological evaluation which have not
been completed. Even when RYGB is considered for unique circumstances to control GERD, it should still
include a dietary and behavioral evaluation given the anatomical, nutritional and behavioral consequences that
can result from the intestinal rerouting that occurs during gastric bypass impacting micronutrient absorption,
potential for dumping, reactive hypoglycemia, ETOH metabolism changes that should all be discussed.

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 laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y
gastroenterostomy (roux limb 150 cm or less) (CPT Code 43644).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on July 
30, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that the comprehensive evaluation 
had to be done because you were seen by a new dentist. The Plan denied your request. The Plan says this 
service exceeds the frequency limitation in your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, comprehensive oral evaluation 
(D0150) is limited to one procedure every three plan years. The record shows that you received a 
comprehensive oral evaluation (D0150) on January 29, 2020, and your comprehensive oral evaluation (D0150) 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive 
oral evaluation (D0150) provided on July 30, 2020.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the cost for an urgent care visit. We decided that the Plan does not have 
to reduce the cost for an urgent care visit.  
 
You asked the Plan to reduce the cost for an urgent care visit. You say that this cost-sharing should be 
reconsidered. The Plan says that the correct copayment was applied. 
 
We decided that the Plan has to reduce the cost for an urgent care visit.  
 
The case record shows that the services were provided at an urgent care facility. Your contract with the plan 
clearly says that you pay 20% coinsurance for urgently needed services at an urgent care center. The Plan-
allowed amount is $51.52 (20% x $51.52 = $10.30). Therefore, we decided that the Plan has to reduce the cost 
for an urgent care visit.  
 
We also decided that the Plan does not have to waive the cost for an urgent care visit. 
 
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 urgently needed services at an urgent care center. Therefore, we decided that the Plan does not 
have to waive the cost for an urgent care visit. 
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the evaluation and management service provided on August 
19, 2020. 
 
You asked the Plan to pay for prolonged evaluation and management service before and/or after direct patient 
care; first hour (99358). You say that the Plan should pay this claim. The Plan denied your request. The Plan 
says the code submitted is not a telephone evaluation and management service code according to their PHP 
Payment Policy 92.0. 
 
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 99358 is Prolonged evaluation and management service 
before and/or after direct patient care; first hour. 
 
We find that CPT code 99358 is not the correct code for telephone services based on the CMS Covered 
Telehealth Services for the COVID-19 Pandemic. Based on this information, we decided that Medicare rules 
for coverage of prolonged evaluation and management service before and/or after direct patient care; first hour 
(99358) have not been met. Therefore, we decided that the Plan does not have to pay for the evaluation and 
management service provided on August 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve protein, total, except by refractometry; serum, plasma or 
whole blood (CPT Code 81455). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the molecular testing is not indicated unless stage four (IV) disease. Similarly same for PDL1 
and TMB, MSI. 
 
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 protein, total, except by refractometry; serum, plasma or whole blood (CPT Code 81455).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee on January 
9, 2020. 
 
You asked the Plan to pay for home health services. You say that this was medically necessary. The Plan 
denied your request. The Plan says this was not billed with a HIPPS code. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, this claim 
was not billed with the required HIPPS code. Therefore, we decided that the Plan does not have to pay for the 
home health services provided to the enrollee on January 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on February 21, 2020, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved 
for payment. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 an office visit provided on February 21, 2020, by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for assistant at surgery services provided on June 16, 2020. 
 
You asked the Plan to pay for assistant at surgery services. You say that this code is payable to the assistant 
surgeon. The Plan denied your request. The Plan says the denial of payment for this service is correct, because 
an assistant at surgery may not be paid for this service. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 
64721. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means 
that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based 
upon this information, we find that Medicare coverage criteria for assistant at surgery services have not been 
met. Therefore, we decided that the Plan does not have to pay for assistant at surgery services provided on June 
16, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered on June 11, 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 claim was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home 
health services under a plan of treatment. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the correct TOB 
code. 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 home health services rendered on June 
11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for chemotherapy administration with 
injection of omalizumab (94601, J2357) provided April 29, 2020, to June 24, 2020. 
 
You asked the Plan to waive the coinsurance for chemotherapy administration with injection of omalizumab. 
You say that you thought that these services were covered. The Plan denied your request. The Plan says the 
coinsurance 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 20% 
coinsurance for Medicare-covered chemotherapy drug and its administration.  
 
You have been asked to pay a total cost share of $2,299.15 for chemotherapy administration with injection of 
omalizumab. Each date of service was billed with a coinsurance of 20% for the chemotherapy drug and its 
administration fee for a total cost share of $459.83 ($14.07 + 445.76). You had five dates of service for a total 
cost share of $2,299.15 ($459.83 x 5). The services provided fall within the Medicare-covered chemotherapy 
drug and its administration 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 
chemotherapy administration with injection of omalizumab (94601, J2357) provided April 29, 2020, to June 
24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laminectomy and fusion spinal surgery. 
 
You asked the Plan to pre-approve the laminectomy and fusion procedure. You say that the imaging evidence 
supports that this procedure is required to treat the enrollee's condition. The Plan denied your request. The Plan 
says the surgery is not shown to be medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the laminectomy and fusion procedure. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the medical records do not show that there is an incapacitating level of 
documented pain. There is no documented radiographic instability on flexion and extension films. Fusion 
surgery criteria are not met. 
 
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 laminectomy and fusion procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve laminectomy and fusion spinal surgery.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drug injection and does 
not have to waive the copayment for the administration provided on July 11, 2019. 
 
You asked the Plan to waive the coinsurance for a Medicare Part B drug injection and to waive the copayment 
for the administration. You say that you disagree with how the claim was billed because it resulted in the Plan 
not covering the charges. 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. Your contract with the Plan also clearly says that you must 
pay a $295 copayment for outpatient surgery and other medical services provided at hospital outpatient 
facilities and ambulatory surgical centers. 
 
You received a Medicare Part B drug injection on July, 2019. The allowed amount is $2,048.35 and 20% of 
that is $409.67. You are also responsible to pay the total allowed amount of $209.25, which is less than the 
copayment amount, for the administration. The total amount you owe is: $618.92.   
 
You have been asked to pay the total amount of $618.92 for a Medicare Part B drug injection and the 
administration. A Medicare Part B drug injection falls within the Medicare Part B prescription drugs benefit 
category. The administration falls within the outpatient surgery and other medical services provided at hospital 
outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
coinsurance for Medicare Part B drug injection and does not have to waive the copayment for the 
administration provided on July 11, 2019.