Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an allergy specialist office service provided 
on December 13, 2021. 
 
You asked the Plan to waive the copayment for an allergy specialist office service. You say that you were 
previously told this should be a 100% covered expense. 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 $35 
copayment for a specialist visit.  
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
the allowed amount of $10.92, which is less than the $35 copayment for an allergy specialist office service. An 
allergy specialist office service 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 an allergy specialist office 
service provided on December 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically reasonable 
and necessary. The Plan denied your request. The Plan says the requested procedure 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 the Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex procedure is experimental. More research is needed before coverage can 
be approved. 
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the epidural injection provided on 
November 8, 2021. 
 
You asked the Plan to waive the copayment for epidural injection. You say that you were not treated as a 
surgery patient, but you are being charged as if you were. The Plan denied your request. The Plan says 
copayment 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 $300 
copayment for Medicare-covered services at an in-network ambulatory surgical center.  
  You have been asked to pay $300 for epidural injection. The epidural injection 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 waive the copayment for the epidural injection provided on November 8, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test (G0480) rendered by the out-of-network (OON) 
provider on November 29, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the drug test (G0480) rendered by the out-of-network (OON) provider on  
November 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services provided 
on November 18, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. 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 $250 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $250 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance Services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
ambulance transportation services provided on November 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 1, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says prior authorization is required for an out-of-network 
visit. 
 
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 laboratory services provided on December 1, 2021 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the home ventilator is medically reasonable 
and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the requested home ventilator is not medically reasonable and necessary. Our physician reviewer found a 
home ventilator is not medically necessary. This patient has a diagnosis of COPD, but there are no pulmonary 
function tests for confirmation or to assess severity.  She also has mild obstructive sleep apnea. Sleep studies 
have shown hypoxemia and hypoventilation during sleep, although there is no arterial blood gases test to confirm chronic CO2 retention when awake. Positive airway pressure titrations were unsuccessful with 
continuous positive airway pressure and bilevel positive airway pressure; the patient did better with average 
volume-assured pressure support. However, average volume-assured pressure support mode can be provided 
via and bilevel positive airway pressure device, and Medicare does not cover a home ventilator when used as 
and bilevel positive airway pressure. The denial of the ventilator is upheld. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214), tangential biopsy of skin (11102), 
and the destruction of lesions (17110) rendered by the out-of-network (OON) provider on October 12, 2021. 
 
You asked the Plan to pay 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 services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 the office visit (99214), tangential biopsy of skin (11102), and the destruction of 
lesions (17110) rendered by the out-of-network (OON) provider on October 12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit and related services to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visit and related services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says there are in-network providers available to provide this 
medical care immediately. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visit and related services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the influenza virus vaccine (90688) and the administration of 
the influenza virus vaccine (G0008) rendered by the out-of-network (OON) provider on November 15, 2021. 
 
You asked the Plan to pay for this item/service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this item/service were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the item/service 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 this item/service. Therefore, we decided that the Plan does not have to pay for the influenza virus 
vaccine (90688) and the administration of the influenza virus vaccine (G0008) rendered by the out-of-network 
(OON) provider on November 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213), routine venipuncture (36415), and 
the laboratory service (82947) rendered by the out-of-network (OON) provider on November 15, 2021. 
 
You asked the Plan to pay 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 services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 the office visit (99213), routine venipuncture (36415), and the laboratory service 
(82947) rendered by the out-of-network (OON) provider on November 15, 2021.
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 from July 
9, 2021 to August 6, 2021. 
 
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the provider did not follow Medicare 
guidelines for submitted the RAP. 
 
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, the record 
indicates that the RAP was not submitted within 5 days of the start of services. Therefore, we decided that the 
Plan does not have to pay for the home health services provided to the enrollee from July 9, 2021 to August 6, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cerebral perfusion analysis (0042T) provided on November 
26, 2021. 
 You asked the Plan to pay for cerebral perfusion analysis. You say that this service was performed at the 
recommendation of the patient's teleneurologist. The Plan denied your request. The Plan says this service was 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that cerebral perfusion analysis is considered medically 
necessary and coverable for patients with acute ischemic stroke (AIS) caused by unilateral large vessel 
occlusion (LVO) in the proximal anterior circulation evaluated at stroke centers, to aid in selection for 
endovascular mechanical thrombectomy (EVT) 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 pay for cerebral perfusion analysis. Our reviewer 
says that the patient did not meet criteria for this service. Our physician reviewer found the patient did not have 
acute occlusion of the internal carotid or the middle cerebral arteries and there is no documentation that 
endovascular mechanical thrombectomy was under consideration. Therefore, the service was 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 cerebral perfusion analysis have not been met. Therefore, we decided that the 
Plan does not have to pay for cerebral perfusion analysis (0042T) provided on November 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal aortography (75625) provided on December 
29, 2021. 
 You asked the Plan to pay for the abdominal aortography. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT 75625 and 
37244. 
 
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, we have confirmed that code 75625 is a column II code to column I code 37244; however, 75625 
was billed with a modifier.  
 
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 abdominal aortography. Our reviewer says that CPT code 
75625 does not meet criteria for billing or reimbursement consideration. Our reviewer found the procedure 
report does not support additional radiological services were separate from vascular occlusion procedure, 
which includes serialography, radiological supervision and interpretation services per CPT code description.  In 
this case,  CPT 75625 is inclusive to CPT 37244, and would not be reported separately. 
 
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 abdominal aortography have not been met. Therefore, we decided that the 
Plan does not have to pay for the abdominal aortography (75625) provided on December 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nasal surgery services provided on October 5, 2021. 
 
You asked the Plan to pay for the nasal surgery services. You say that this surgery has helped you and should 
be reprocessed for payment. The Plan denied your request. The Plan says prior authorization is required for all 
surgery services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the nasal surgery services provided on 
October 5, 2021, have been met. In this case, no medical records were received to verify the medical necessity 
of the surgery services that were received. Therefore, we decided that the Plan does not have to pay for the 
nasal surgery services provided on October 5, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
November 27, 2021. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you were instructed to go to the ER 
by your doctor after complications from your COVID-19 vaccine booster. You also say you feel it should be 
covered by Medicare due to being a vaccine injury. 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 $90 
copayment for an emergency room visit.  
 
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$90 copayment for an ER visit. An ER visit falls within the Emergency 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 an emergency room (ER) visit provided on November 27, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing services of between 8-14 classes provided on 
September 9, 2021. 
 
You asked the Plan to pay for the drug testing services. You say that you would like this claim reprocessed 
based on the medical documentation. The Plan denied your request. The Plan says that only 7 drug classes were 
tested per the lab results that have been submitted. 
 
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 the medical records support that drug testing services of between 8-14 classes is supported by the 
medical documentation. Specifically, we examined the record and determined this based on verifying the drugs 
tested with the Official CPT coding manual. Based on this information, we decided that Medicare rules for 
coverage of the drug testing services have been met. Therefore, we decided that the Plan has to pay for the drug 
testing services of between 8-14 classes provided on September 9, 2021.  
 
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.