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

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 17, 2021. 
 
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 not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on September 17, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. The Plan denied your request. The Plan says 10 
additional PT visits are not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 
  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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the additional requested therapy generally is not accepted as specific 
and effective therapy for the patients condition beyond what was approved by the health plan. Our reviewer 
found that the patient has had prior therapy and the documentation does not reveal that the patient requires the 
unique skills of a professional therapist to safely and effectively provide treatment, that the services can be 
safely and effectively performed only by a therapist, or by or under the supervision of a therapist. Our 
physician reviewer also found that the requested services are not part of a maintenance program, and the 
specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or 
deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 10 additional physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient observation on December 23, 
2021 to December 24, 2021. 
 
You asked the Plan to waive the copayment for outpatient observation. You say that there should only be a $90 
copay for an ER visit. The Plan denied your request. The Plan says the cost share applied is correct. 
 
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 $50 
copayment for outpatient observation.  
 
You have been asked to pay a $50 copayment for outpatient observation. Outpatient observation falls within 
the Physician/Practitioner services, including doctors 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 copayment for outpatient observation on December 23, 2021 to December 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (93460) provided on November 30, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed 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 93460 is "Catheter placement in coronary artery(s) for 
coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision 
and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left 
ventriculography, when performed". 
 
We asked our coder 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 the services. Our reviewer says that the use of code 93460 is 
not supported by the records provided. Our reviewer found that the operative report documents "Using a flashback needle with the Seldinger technique the right femoral artery was successfully accessed in a retrograde 
fashion over the guidewire using a Introducer Shth 4fr 80cm 23cm Red Hub Gw. The left coronary artery was 
selectively engaged and injected. A (Catheter 4fr Jr4 Mod Crv 100cm Lg Inner Lum Radopq) catheter was 
used to cross the aortic valve and placed in the left ventricle. LV pressure was recorded and measured".  This 
procedure code cannot be verified, due to lack of documentation. 
 
We looked at this coder'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 pay for the services (93460) provided on November 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone marrow aspirate. 
 
You asked the Plan to pre-approve a bone marrow aspirate. You say that a bone marrow aspirate is medically 
necessary. The Plan denied your request. The Plan says medical studies haven't proven that the requested 
procedure 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 bone marrow aspirate. Our reviewer 
says that a bone marrow aspirate is not medically reasonable and necessary. Our physician reviewer found 
detailed documentation is not evident regarding a specific indication provided to support the request for bone 
marrow aspirate for the approved surgery. There is a lack of large volume, long-term peer-reviewed outcome 
studies to support the use of bone marrow aspirate for this enrollees medical condition. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception to guidelines. 
 
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 bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bone marrow aspirate.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 11, 2021. 
 
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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, 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 the laboratory services rendered on January 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stab phlebectomy and endovenous ablation therapy. 
 
You asked the Plan to pre-approve vein procedures. You say that the enrollee has failed conservative therapy 
and needs treatment to continue having good quality of life. The Plan denied your request. The Plan says the 
denial of authorization for this service is correct, because the enrollee does not meet coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules state that invasive vein treatment procedures may be 
reasonable and necessary when certain criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve vein procedures. Our reviewer says that 
the enrollee does not meet the Medicare criteria for the requested vein procedures. Our physician reviewer 
found the venous clinical severity score (VCSS) has not been provided. Additionally, the enrollee is minimally 
symptomatic. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of vein procedures have not been met. Therefore, we decided that the Plan does 
not have to pre-approve stab phlebectomy and endovenous ablation therapy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orencia for the enrollee 
 
You asked the Plan to pre-approve Orencia. You say that this will be beneficial for the enrollee. The Plan 
denied your request. The Plan says that you do not document that the enrollee has tried and failed Avsola, 
Inflectra, and Renflexis or Simponi Aria or that the enrollee is unable to tolerate either Avsola, Inflectra, and 
Renflexis or Simponi Aria. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met.  
 
We looked at the file and Medicare rules. Specifically, medical records were not provided for review in this 
case. The record shows that the Plan made multiple attempts to secure medical records, without success. 
Without medical records, we cannot determine if criteria for coverage are met in this case. Based on this 
information, we decided that Medicare rules for coverage of Orencia have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Orencia for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a spinal injection performed on December 
22, 2021. 
 
You asked the Plan to reduce the copayment for the injection. You say that you believe it was just an injection 
instead of surgery. You say that you should only have a smaller coinsurance instead of the copayment. The 
Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $350 
copayment for outpatient procedures and services, such as injections.  
 
You have been asked to pay a $350 copayment for the injection. The injection is considered a surgical 
procedure and falls within the Outpatient Surgery, Including 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 reduce the copayment for a 
spinal injection performed on December 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital lab services provided on September 
15, 2021. 
 
You asked the Plan to pay for the outpatient hospital lab services. You say that this should be paid. The Plan 
denied your request. The Plan says a non-OPPS code was used on this claim which prevents payment. A 
corrected claim is necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that all outpatient hospital claims are subject to the 
I/OCE which includes edits to prevent improper payment. 
 We looked at the file and Medicare rules. This claim was denied per OCE edit 62. According to the Centers for 
Medicare and Medicaid Services I/OCE Specifications, Version 22.2, edit 62 denotes that a code that is "not 
recognized by Medicare for OPPS" was used. We confirmed that code 80321 has a status indicator of B in the 
OPPS. The disposition for a claim with this edit is to return to provider meaning the claim is denied payment. 
Based on this information, we decided that Medicare rules for coverage of the outpatient hospital lab services 
have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient hospital lab 
services provided on September 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sock aid, reacher, and cane purchased on December 3, 
2021. 
 
You asked the Plan to pay for the sock aid, reacher, and cane. You say that the items are medically necessary. 
The Plan denied your request. The Plan says these are not covered items. 
 
The Plan must follow Medicare rules. Medicare rules say that the Plan must cover what Medicare would cover. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the sock aid, reacher, and cane have not been met. Therefore, we decided that the Plan does not 
have to pay for the sock aid, reacher, and cane purchased on December 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the injections provided on January 11, 
2022. 
 
You asked the Plan to waive the coinsurance for the injections. You say that you shouldn't have to pay more 
than your $35 copayment. The Plan denied your request. The Plan says the coinsurance applied is correct. 
 
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 and 20% coinsurance for each Medicare-covered medical 
supply. 
 
  You have been asked to pay a total of $95.69 for the injections. 
 
Service Allowed Amount Coinsurance Member Liability 
Aminophylline Injection $8.57 20% $1.71 
Dipyridamole Injection $21.90 20% $4.38 
Rubidium RB-82 Injection $448 20% $89.60 
TOTAL:   $95.69 
 
The aminophylline injection and dipyridamole injection fall within the Medicare Part B Prescription Drugs 
benefit category. The rubidium RB-82 injection falls within the Outpatient Diagnostic Tests and Therapeutic 
Services and Supplies benefit category. Medicare Part B drugs and medical supplies are considered a separate 
service. 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 the injections provided on January 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT scan, abdomen; without contrast material, followed 
by contrast material(s) and further sections (CPT code 74170). 
 
You asked the Plan to pre-approve the CT scan. You say that the service is necessary. The Plan denied your 
request. The Plan says the clinical documentation received does not support medical necessity for follow-up 
imaging at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 CT scan. Our physician reviewer 
found the clinical documentation received does not support medical necessity for follow-up imaging at this 
time. Based on the guidelines, follow-up interval imaging could be approved at the earliest date of December 9, 
2022. The review has determined that the requested CT scan is 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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve CT scan, abdomen; without contrast material, followed by contrast material(s) and further 
sections (CPT code 74170).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a home ventilator provided from 
September 20, 2021, to December 20, 2021.  
 
You asked the Plan to waive the coinsurance for a home ventilator. You say that the cost share is too high and 
unaffordable. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
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 in-network durable medical equipment.  
 You have been asked to pay $169.81, which is 20% coinsurance of the allowed amount for each home 
ventilator received on September 20, 2021, October 20, 2021, November 20, 2021, and December 20, 2021 
($849.04 allowed amount x 20% coinsurance = $169.81). A home ventilator falls within the Durable Medical 
Equipment (DME) and Related 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 coinsurance 
for a home ventilator provided from September 20, 2021, to December 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on January 25, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the specialist office visit. You say that you have provided the medical records 
related to the service rendered and would like payment for the service that was provided to the enrollee. The 
Plan denied your request. The Plan says the rendering provider is an OON provider and there was no referral 
from an in-network provider or an approved authorization. Also, the service rendered was not urgent or 
emergent. 
 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 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 a specialist office visit provided on January 25, 
2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says there is no history of 
osteoporosis-related fracture, and the enrollee has not tried and failed zoledronic 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our physician reviewer found 
that the enrollee has a diagnosis of age-related osteoporosis without current pathological fracture. The health 
plan requires a trial of zoledronic acid, or a history of an osteoporosis-related fracture before they will approve 
the requested drug. There is no indication that the enrollee has tried and failed the required drug or has a history 
of an osteoporosis-related fracture. There is no indication that the Plan's required drug would likely be less 
effective or likely have adverse effects 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmic diagnostic imaging provided on July 13, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for ophthalmic diagnostic imaging. You say that you were told these services would 
be covered. The Plan denied your request. The Plan says the services were provided out-of-network and were 
not approved in advance. 
 
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 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 ophthalmic diagnostic imaging provided on July 
13, 2021 by an out-of-network (OON) provider.