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

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (99213) provided on 
December 9, 2021, 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you were given an 
appointment date beyond the 90 day global period, and you did not get a reason for that. You also say you 
would like this copayment waived. The Plan denied your request. The Plan says you were 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 $45 
copayment for each Medicare-covered specialist office visit.  
 
You have been asked to pay a $45 copayment for a specialist office visit. A specialist office visit 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 a specialist office visit (99213) provided on December 9, 2021,
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You did not provide an argument with your appeal request. The 
Plan denied your request. The Plan says IRF care is not medically necessary for the enrollee. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require the intensity of services provided at an IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and 
regular physician evaluation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for Administration of Part B drugs at an 
outpatient Hospital from October 20, 2021 to October 26, 2021. 
 
You asked the Plan to waive the copayments for Administration of Part B drugs at an outpatient hospital. You 
say that you are requesting that the plan pay the bill. The Plan denied your request. The Plan says requests the 
plan pay the bill 
 
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 each day Part B drugs were administered at an outpatient hospital. The allowed amount is 
$185.26 per day, resulting in a total copayment amount of $1,111.56 because this is less than the $350 
members copayment. You have been asked to pay a $350 copayment for each day Part B drugs were administered at an outpatient 
hospital. Administration of Part B drugs at an outpatient hospital 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 copayments for Administration of Part B drugs at an outpatient Hospital 
from October 20, 2021 to October 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit provided on November 9, 2021. 
 
You asked the Plan to pay for an annual wellness visit. The Plan denied your request. The Plan says the benefit 
has been exhausted. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for an annual wellness visit provided on  
November 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (88305, 88313, 88342) provided on 
August 3, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the referring physician ordered specialized 
testing for this patient and forwarded the tests directly to you. You also say that you only perform the testing 
services, and you do not have direct patient contact. The Plan denied your request. The Plan says services from 
an out-of-network provider are not covered without first getting prior authorization from the Plan, except in 
certain situations. The Plan also says that there were no medical records to establish medical necessity for this 
appeal request. 
 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 (88305, 88313, 88342) 
provided on August 3, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an X-ray of the chest (71045) provided on July 1, 2021. 
 You asked the Plan to pay for a chest X-ray. You say that the service at issue was a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the CPT 
code at issue is inclusive to another billed code. 
 
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 71045 
is a column II code to column I code 74022. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for an X-ray of the chest (71045) provided on July 1, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided from May 26, 2021, 
through August 25, 2021. 
 
You asked the Plan to pay for psychotherapy services. The Plan denied your request. The Plan says that the 
provider must attempt to consult the attending or primary care physician about the services furnished and 
document the consent or declination date to consultations, and the date of consultations in the patients medical 
record. There was no documentation of contact in the patient record. The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy services have not been met. Specifically, the record does not include documentation 
of a consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare 
rules. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided from 
May 26, 2021, through August 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 19, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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 the laboratory 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 provided on March 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injections (J3301, J1100, 64483). 
 
You asked the Plan to pre-approve the injections. You say that the injections are 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 repeat injections are covered when there is at 
least 50% of sustained improvement in pain relief and/or improvement in function measured from baseline 
using the same scale for at least 3 months. 
 
We looked at the file and Medicare rules. The last set of injections was less than 3 months ago. Based on this 
information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we 
decided that the Plan does not have to pre-approve injections (J3301, J1100, 64483).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist office visits provided from 
March 24, 2021, to September 24, 2021. 
 
You asked the Plan to waive the copayments for the specialist office visits. You say that you cannot afford to 
pay $100 for each appointment. 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 $15 
copayment for each visit with a specialist.  
 You have been asked to pay a $15 copayment for each of the 3 specialist office visits, for a total of $45. The 
specialist office visits fall within the Physician/Practitioner Services, Including Doctor's 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 copayments for specialist office visits provided from March 
24, 2021, to September 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Physical Therapy Evaluations provided on September 30, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Physical Therapy Evaluations. You say that you are appealing claim payment 
denial for services rendered. The Plan denied your request. The Plan says the provider should have verified the 
member's eligibility, health benefits and obtained authorization prior to the members visit before providing 
services to the member as outlined on the member's ID card. 
 
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 Physical Therapy Evaluations provided on 
September 30, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay from June 27, 
2021, to July 6, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you are unable to pay 
this amount. The Plan denied your request. The Plan says the copayment 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 $195 
copayment each day for the first six days for Medicare-covered hospital care.  
 
 
 You have been asked to pay a $1,170 copayment ($195 x 6 days) for the first six days for the inpatient hospital 
stay. The inpatient hospital stay 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 the inpatient hospital stay from June 27, 2021, to July 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
thorax (71250) provided on September 17, 2021. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan of the thorax. You say that 
in the past you have not received a bill for this, and you do not understand why you all of a sudden are billed 
for this service this time. The Plan denied your request. The Plan says you were 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 $160 
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a 
physician's office or at a free-standing facility (such as a radiology center or medical clinic). Your contract with 
the Plan also says that the diagnostic radiology services require specialist equipment beyond standard x-ray 
equipment and must be performed by specially trained or certified personnel, and an example includes, but is 
not limited to, CT scans.  
 
You have been asked to pay $108.43, which is less than the $160 copayment for a computed tomography (CT) 
scan of the thorax. A computed tomography (CT) scan of the thorax 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 
computed tomography (CT) scan of the thorax (71250) provided on September 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve, 
including all imaging guidance; first two vertebral bodies lumbar or sacral (CPT 64628). 
 
You asked the Plan to pre-approve thermal destruction of intraosseous basivertebral nerve, including all 
imaging guidance; first two vertebral bodies lumbar or sacral. The Plan denied your request. The Plan says Plan 
medical policy considers intraosseous ablation of the basivertebral nerve unproven and not literature comparing 
patient outcomes are needed. Published studies do not demonstrate any clear benefit or advantage in VAS or 
quality of life measures. Intracept is investigational and experimental, and member is not receiving this device 
as part of a Medicare covered clinical trial. Therefore, it is not reasonable and 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 thermal destruction of intraosseous 
basivertebral nerve, including all imaging guidance; first two vertebral bodies lumbar or sacral. Our reviewer 
says that the requested thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; 
first two vertebral bodies lumbar or sacral is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the manufacturer sponsored INTRACEPT study comparing the effectiveness 
of intraosseous RFA of the basivertebral nerve (BVN) to standard care for the treatment of chronic low back 
pain thought to be of vertebrogenic origin concluded that the findings are limited by lack of blinding, sham 
intervention, or comparison with established approaches. The review has determined that the requested thermal 
destruction of intraosseous basivertebral nerve, including all imaging guidance; first two vertebral bodies 
lumbar or sacral at issue in this case 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 thermal destruction of intraosseous basivertebral nerve, including all imaging 
guidance; first two vertebral bodies lumbar or sacral have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve, including all imaging 
guidance; first two vertebral bodies lumbar or sacral (CPT 64628).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on August 13, 2021. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent 
or emergent, nor were they 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 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 a domiciliary, rest home visit provided on August 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing (0242U) provided on September 14, 
2021. 
 
You asked the Plan to pay for Guardant360 testing. You say that this was billed correctly. The Plan denied your 
request. The Plan says this was not billed with the correct place of service. 
 
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 Guardant360 testing 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 Guardant360 testing (0242U) provided on September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nerve conduction studies (95908), neuromuscular junction 
testing (95937), and continuous intraoperative neurophysiology monitoring (G0453) provided on June 17, 
2021.  
You asked the Plan to pay for nerve conduction studies, neuromuscular junction testing, and continuous 
intraoperative neurophysiology monitoring. You say that the services at issue were a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the CPT 
codes at issue are inclusive to another billed code. 
 
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 codes 
95908, 95937, and G0453 are column II codes to column I code 51785. This claim has not been billed with 
appropriate modifiers to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for nerve conduction studies (95908), 
neuromuscular junction testing (95937), and continuous intraoperative neurophysiology monitoring (G0453) 
provided on June 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 11, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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 the laboratory 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 provided on January 11, 2021.