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

We decided that the Plan does not have to pay for an ultrasound of the heart (93306) provided on February 15, 2021, by an out-of-network provider.
You asked the Plan to pay for an ultrasound of the heart. You say that you disagree with the Plan's refusal to pay for the services at issue. The Plan denied your request. The Plan says rules for out-of-network care 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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for an ultrasound of the heart (93306) provided on February 15, 2021, by an out-of-network provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gamunex-C.
You asked the Plan to pre-approve Gamunex-C. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 Gamunex-C. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the review indicates that the documentation does not support that the Gamunex-C is medically reasonable and necessary for the enrollee. The documentation does not support that the Gamunex-C is safe and effective 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 Gamunex-C have not been met. Therefore, we decided that the Plan does not have to pre-approve Gamunex-C.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on January 19, 2021.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that some of the services were not covered at all and you disagree with 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. You received Medicare Part B drugs on January 19, 2021. The total allowed amount is $10,006.20 and 20% of that is $2,001.24.
You have been asked to pay the total coinsurance amount of $2,001.24 for Medicare Part B drugs. Medicare Part B drugs fall 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 Medicare Part B drugs provided on January 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to adjust the coinsurance for the positron emission tomography (PET) scan (78815) provided on April 1, 2020.
You asked the Plan to adjust the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the service 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 you must pay a 20% coinsurance for all other Medicare-covered diagnostic radiology services (not including x-rays).
You have been asked to pay $604.80 ($3,024 x 20% coinsurance) for the diagnostic radiology service 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 adjust the coinsurance for the positron emission tomography (PET) scan (78815) provided on April 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says experimental or investigational procedures are not covered.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested device is experimental for use in spinal surgery. More research is needed to show safety and efficacy of the device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6.
You asked the Plan to pre-approve a Dexcom G6. You say that the services are necessary. The Plan denied
your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses
adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least
three daily injections. Based on this information, we decided that Medicare rules for coverage of a Dexcom G6
have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87496, 87498, 87532,87541, 87640, 87798) provided March 10, 2021.
You asked the Plan to pay for the lab services. You say that the service was medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that Multiplex PCR respiratory viral panels of 6 or more pathogens are non-covered. We looked at the file and Medicare rules. More than 6 pathogens were tested. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (87496, 87498, 87532,87541, 87640, 87798) provided March 10,
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services provided on September 23, 2020.
You asked the Plan to pay for 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 15 minutes of intraservice time, patient age 5 years or older (99152). You say that because the enrollee had to remain still for a long period of time or in a painful position anesthesia was necessary for the comfort of the patient. The Plan denied your request. The Plan says the enrollee was medially stable without any history of high risk co-morbid conditions to suggest that anesthesia services were warranted.
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. Medical necessity of the moderate sedation service is not clearly documented in the medical record. Based on this information, we decided that Medicare rules for coverage of moderate sedation services (99152) have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services provided on September 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the external receiver represented by code A9278 provided on
September 11, 2020.
You asked the Plan to pay for code A9278. You say that you would like the Plan to reconsider their denial of
payment. The Plan denied your request. The Plan says code A9278 is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that CGM devices that do not meet the definition of a
therapeutic CGM as defined in CMS Ruling 1682R will be denied as non-covered (no benefit).
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of code A9278 have not been met. Specifically, code A9278 has a status code of "N" under the
Medicare Physicians Fee Schedule Database (MPFSDB) and is a non-covered code per Medicare guidelines.
Therefore, we decided that the Plan does not have to pay for the external receiver represented by code A9278
provided on September 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs and does not have to waive the copayments for the administration provided from May 4, 2020, to September 15, 2020.
You asked the Plan to waive the coinsurance for Medicare Part B drugs and to waive the copayments for the administration. You say that you are unhappy with the fact that the charges were not paid. 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 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.
Date of Service
Service Code
Allowed Amount
Amount You Owe
5/4/2020
96372
$57.94
$28.68
6/29/2020
96372
$57.94
$57.94
6/29/2020
J0881
$107.32
$21.46
7/27/2020
96372
$57.94
$57.94
7/27/2020
J0881
$110.72
$22.14
9/15/2020
96372
$57.94
$57.94
9/15/2020
J0881
$110.72
$22.14
The total amount you owe is: $268.24. You have been asked to pay the total amount of $268.24 for Medicare Part B drugs and the administration. Medicare Part B drugs fall 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 drugs and does not have to waive the copayments for the administration provided from May 4, 2020, to September 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve enteral nutrition.
You asked the Plan to pre-approve enteral nutrition. You say that you have an intense dental problem that
requires the requested nutritional drink. The Plan denied your request. The Plan says the requested items are
not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation.
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan
does not have to pre-approve enteral nutrition.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for extremity braces (L1971, L3170) provided August 24, 2020.
You asked the Plan to pay for the extremity braces. You say that the items were medically necessary. The Plan denied your request. The Plan says this item was provided as a result of an unsolicited telehealth consult.
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances. We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the
enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the extremity braces have not been met. Therefore, we decided that the Plan does not have to pay for extremity braces (L1971, L3170) provided August 24, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869 and 22870), for the enrollee.
You asked the Plan to pre-approve the surgery. You say that the enrollee has suffered with back pain for over a year and has tried conservative treatment that has failed. The Plan denied your request. The Plan says the services are considered experimental and 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 the surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869 and 22870), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be rendered by the out-of-network (OON) provider.
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.
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 service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an office visit to be rendered by the out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. You say that the requested Keytruda is medically necessary. The
Plan denied your request. The Plan says the requested Keytruda is not medically necessary.
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 Keytruda. Our reviewer says that the
requested Keytruda is not medically necessary. Our physician reviewer found the requested use of Keytruda is
not FDA-approved for the enrollee's diagnosis. There is no evidence for testing of EGFR or ALK. The use of
Keytruda is not supported by one of the major drug compendia or by clinical research that appears in a CMSapproved
medical journal for the enrollee's diagnosis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have
to pre-approve Keytruda.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided January 29, 2021, through February 5, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were not satisfied with your hospital stay. The Plan denied your request. The Plan says the copayment has been 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 $265 copayment per day, per stay for days 1-7 of inpatient hospital care. You have been asked to pay a total of $1,650 ($265 copayment x 7 days up to your maximum out-of-pocket amount of $1,900) for the inpatient hospital services. These services fall 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 services provided January 29, 2021, through February 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy) (CPT code 43775), for the enrollee.
You asked the Plan to pre-approve the laparoscopy. You say that the enrollee has tried appetite suppressants and had minor weight loss. You state the enrollee has hypothyroidism, arthritis, gastroesophageal reflux disorder, stannosis and depression. You state the surgery can help these issues. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laparoscopy have not been met. The record sent by the provider indicates the enrollee's most recent body mass index (BMI) is documented as 31.2 on May 20, 2021. Last year in October 2020 the enrollee's BMI was 31.3. The enrollee is taking prescription medication to try to help their weight loss efforts. The rules say that effective for services performed on and after June 27, 2012, Medicare Administrative Contractors (MACs) acting within their respective jurisdictions may determine coverage of stand-alone laparoscopic sleeve gastrectomy (LSG) for the treatment of co-morbid conditions related to obesity in Medicare beneficiaries only when all of the following conditions a.-c. are satisfied. a. The beneficiary has a body-mass index (BMI) greater than or equal to 35 kg/m2, b. The beneficiary has at least one co-morbidity related to obesity, and, c. The beneficiary has been previously unsuccessful with medical treatment for obesity. Therefore, we decided that the Plan does not have to pre-approve the laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy) (CPT code 43775), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the posterior interspinous decompression spacer procedure, for the enrollee.
You asked the Plan to pre-approve the surgery. You say that the enrollee has been suffering from debilitating disease for over two (2) years. The Plan denied your request. The Plan says the services are considered experimental and 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 the surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found interspinous spacers are experimental. More research is needed to show safety and efficacy of the devices. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the posterior interspinous decompression spacer procedure, for the enrollee.