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

 
We decided that the Plan does not have to pre-approve a Novolog Flexpen. 
 
You asked the Plan to pre-approve Novolog Flexpen. You say that the requested medication is medically 
necessary. The Plan denied your request. The Plan says the claim denied correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve a Novolog Flexpen.  
 
Benefits for Novolog Flexpen may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic examination (71045) provided on January 20, 
2022. 
 
You asked the Plan to pay for code 71045. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the records do not support the billing of two chest x-rays 
performed by this provider on this date of service. 
 
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 radiologic examination (71045) 
provided on January 20, 2022, have been met. In this case, there were no medical records provided confirming 
that two separate radiologic examinations (71045) were provided January 20, 2022, by this provider. The file 
shows that the Plan paid for one claim submitted with code 71045 by this provider. Therefore, we decided that 
the Plan does not have to pay for the radiologic examination (71045) provided on January 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
January 3, 2022, to January 5, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you were informed that you did 
not owe a 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 $390 per 
day for days 1-5 and $0 per day for additional days for each inpatient admission.  
 
The file shows that you were in the hospital from January 3, 2022, to January 5, 2022, but there is no 
copayment for the discharge date. Therefore, you have been asked to pay $390 per day for the first two days of 
inpatient care. The total for your stay is $780 ($390 copayment x 2 days = $780). The inpatient care falls 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 inpatient 
hospital care provided from January 3, 2022, to January 5, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zioptan drops. 
 
You asked the Plan to pre-approve Zioptan drops. You say that the requested medication is medically 
necessary. The Plan denied your request. The Plan says the requested drug is considered self-administered. The 
Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also 
says the requested drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Zioptan drops.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc. 
 
You asked the Plan to pre-approve Orthovisc. You say that the injections are medically necessary. The Plan 
denied your request. The Plan says in order for the request to be eligible for coverage, it must be supplied by 
your medical provider or medical facility. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Orthovisc.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cataract surgery provided on June 15, 2021, 
and July 22, 2021. 
 
You asked the Plan to waive the copayment for cataract surgery. You say that you cannot afford these 
copayments and they should be covered. The Plan denied your request. The Plan says the copayments applied 
are 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 $350 
copayment per day for other outpatient procedures and services, including, but not limited to, diagnostic and 
therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical 
center. 
 
 You have been asked to pay a total of $700 for both cataract surgeries. Cataract surgery 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 cataract surgery provided on 
June 15, 2021, and July 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
 
We decided that the Plan does not have to waive the cost share for cataract surgery provided on October 4, 
2021. 
 
You asked the Plan to waive the cost share for cataract surgery. You say that this surgery should be covered. 
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 $275 
copayment for the surgery services after you reach your $1000 deductible. At the time of the services the 
deductible had not yet been reached. 
 You have been asked to pay a total of $1,103.42 for the cataract surgery. Cataract surgery 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 cost share for cataract surgery provided on 
October 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an upper extremity study and duplex scan 
provided on February 23, 2022. 
 
You asked the Plan to waive the coinsurance for the extremity study and duplex scan. You say that these 
services were always covered in the past. The Plan denied your request. The Plan says the correct coinsurance 
was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for X-rays and ultrasounds. 
 
Service Allowed Amount 20% Coinsurance 
Duplex Scan $69.19 $13.84 
Extremity Study $144.31 $28.86 
Total:  $42.70 You have been asked to pay $42.70, which is 20% of the allowed amount for the extremity study and duplex 
scan. The extremity study and duplex scan fall within the Outpatient Diagnostic Tests and Therapeutic Services 
and Supplies benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an upper extremity study 
and duplex scan provided on February 23, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesia services (01992) provided on November 19, 2021. 
 
You asked the Plan to pay for code 01992. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's limited case file submitted to us includes no citation to a 
specific rule upon which this denial was based. There was no analysis provided by the Plan as to what rule was 
applied and why the services you rendered fit within that rule. Without this information, we cannot determine if 
the Plan's denial was appropriate. The burden is on the Plan to support why its denial is appropriate. The 
minimal information the Plan provided in the case file it submitted to us does not substantiate its denial. 
Therefore, we decided that the Plan has to pay for the anesthesia services (01992) provided on November 19, 
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.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on  
November 11, 2021. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you were advised by the provider 
that there would not be a copayment. The Plan denied your request. The Plan says the copayment applied was 
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 $40 
copayment for routine radiology per provider, per date of service.  
 
You have been asked to pay a $40 copayment for an ultrasound. An ultrasound falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for an ultrasound provided on November 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on January 19, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that it is the facilities responsibility to obtain prior 
authorization and you would like the claim reprocessed for payment. 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 home health visit provided on January 19, 2022, 
by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breast ultrasound provided on February 
14, 2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you needed the additional test due 
to finding a spot on your breast from the routine mammogram. 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 $100 
copayment per day for ultrasounds.  
 
You have been asked to pay $98.58, which is less than the $100 copayment for the ultrasound. The ultrasound 
falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for a breast ultrasound provided on February 14, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from January 5, 2021, to February 1, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this provider has not submitted any clinical records to support the medical necessity of this 
service. 
 
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 skilled nursing facility (SNF) services provided to the enrollee from January 5, 2021, to February 1, 2021 have been met. Despite documentation of 
multiple attempts to receive this information, the provider did not send in any medical records to verify the 
necessity of these services.. Therefore, we decided that the Plan does not have to pay for skilled nursing facility 
(SNF) services provided to the enrollee from January 5, 2021, to February 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the insert helps with balance to avoid falling. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing provided on December 28, 2016. 
 
You asked the Plan to pay for the drug testing. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that this service was up coded 
 
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 G0482 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the lab report clearly shows that 
15-21 drug classes were tested in this case. Please note, we counted the classes based on the separately billable 
tests from the CPT Handbook. Also, the record indicates that this provider was directed by the Plan to not 
obtain records. With this direction, it is inappropriate for the Plan to deny these services based on the physician 
signature. Based on this information, we decided that Medicare rules for coverage of the drug testing have been 
met. Therefore, we decided that the Plan has to pay for the drug testing provided on December 28, 2016.  
 
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 pre-approve an attended sleep study (95810). 
 
You asked the Plan to pre-approve an attended sleep study. You say that the requested service is medically 
necessary. The Plan denied your request. The Plan says the service at issue is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an attended sleep study. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has symptoms suggestive of obstructive sleep apnea. The enrollee does 
not have clinical characteristics that would necessitate an attended study, such as very severe obesity, severe 
heart or lung disease, or neuromuscular disease. The medical records do not provide an explanation of why an 
attended study would be necessary. A home sleep study is a reasonable first step. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an attended sleep study have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an attended sleep study (95810).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve joint ablation procedures (64636, 64635). 
 
You asked the Plan to pre-approve joint ablation procedures. You say that the requested service is medically 
necessary. The Plan denied your request. The Plan says the requested service is not medically necessary 
because the records show the enrollee already had more than the allowed two radiofrequency ablations in this 
spinal region in the preceding 12-month period. 
   
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. There are also specific LCD criteria defining a reasonable and necessary joint 
ablation, as well as frequency limitations as noted in the Medicare rules section of this letter. 
 
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 joint ablation procedures. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the procedure exceeded utilization parameters. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of joint ablation procedures have not been met. Therefore, we decided that the 
Plan does not have to pre-approve joint ablation procedures (64636, 64635).