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

We decided that the Plan does not have to pay for the office visit rendered on April 30, 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 provider has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office
visit rendered on April 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Supartz injection rendered on April 20, 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 medically necessary.
The Plan must follow Medicare rules. Medicare rules say that Supartz is covered when specific 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 these services. Our reviewer says that the
services were not medically necessary. Our physician reviewer found the enrollee had a Supartz injection for
knee pain. There is no documentation provided indicating the medical necessity for the injection. There was no
documentation of physical exam findings, x-ray findings or response to prior therapies including medical
therapy, physical therapy or previous corticosteroid injections. The criteria for coverage are not met and the injection was not medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the Supartz injection rendered on April 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on 
June 10, 2021. 
 
You asked the Plan to waive the copayment for these services. You say that no polyps were found and there 
should be no copayment. The Plan denied your request. The Plan says the copayment was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $375 
copayment for each Medicare-covered outpatient surgery at an ambulatory surgical center or hospital outpatient 
facility.  
 
Review of the file shows that you received a colonoscopy on June 10, 2021. The records show that the 
colonoscopy was not screening in nature because it was performed for a medical diagnosis of neoplasm of the 
colon due to personal history of colon polyps. You have been asked to pay a $375 copayment for these 
services. These services fall within the Medicare-covered outpatient surgery at an ambulatory surgical center or 
hospital outpatient facility 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 
outpatient surgical services rendered on June 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a magnetic resonance angiography (70544) provided on June 14, 2021.
You asked the Plan to pay for a magnetic resonance angiography. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says this is not separately payable.
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 70544 has a bundled relationship with code 70551 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a magnetic resonance angiography (70544) provided on June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the infliximab-abda injection, biosimilar, (renflexis), 10 mg (Q5104) and acetaminophen/Tylenol (A9270) provided February 10, 2021 to June 16, 2021.
You asked the Plan to pay for the injection and self-administered drug. You say that you thought the cost would be picked up by Original Medicare or covered by your Part D part of your plan. You cannot afford these prices for something that you need. The Plan denied your request. The Plan says the claim was processed with the correct coinsurance was applied per the Evidence of Coverage. Self-administered drugs are not covered under Part B.
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 5% of the total cost for Medicare Part B chemotherapy drugs, associated administration services and all other Medicare Part B drugs for Medicare Part B prescription drugs. You have been asked to pay $396.16 for the injection and self-administered drug. 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. The injection and self-administered drug falls within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay for the infliximab-abda injection, biosimilar, (renflexis), 10 mg (Q5104) and acetaminophen/Tylenol (A9270) provided February 10, 2021 to June 16, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the supervision of a nursing facility enrollee coded 99379 provided on March 31, 
2021. 
 
You asked the Plan to pay for the supervision of a nursing facility enrollee. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
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 99379 is supervision of a nursing facility patient (patient not present) requiring 
complex and multidisciplinary care modalities involving regular development and/or revision of care plans by that individual, review 
of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for 
purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal 
guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or 
adjustment of medical therapy, within a calendar month; 15-29 minutes. 
 
We find that CPT code 99379 is not supported in the medical record. Specifically, this code has a status indicator of "B". A status 
indicator of B means that payment for these services are always bundled into payment for other services not specified and no separate 
payment can be made. Based on this information, we decided that Medicare rules for coverage of the supervision of a nursing facility 
enrollee have not been met. Therefore, we decided that the Plan does not have to pay for the supervision of a nursing facility enrollee 
coded 99379 provided on March 31, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular pathology services provided to the enrollee on 
March 25, 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 if a laboratory assays two or more genes in a patient in parallel, then those two or more genes 
will be considered part of the same panel. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there was no specific clinical rationale for the obtained laboratory study. The review has determined that 
the services at issue in this case medically reasonable and 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for molecular pathology services provided to the enrollee on March 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit coded 99204 provided on December 2, 2020. 
 
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 99204 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and 
moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is 
spent on the date of the encounter. 

We find that CPT code 99204 is not supported in the medical record. Specifically, the documentation does not 
support that the services were provided for a new patient visit. The documentation shows that the enrollee is an 
established patient with this provider. Based on this information, we decided that Medicare rules for coverage 
of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office 
visit coded 99204 provided on December 2, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the continued inpatient stay provided from May 25, 2021, to May 26, 
2021. 
 
You asked the Plan to pay for the continued inpatient stay. You say that you do not agree with the amount that 
the enrollee is being charged because it is for the entire time she was in the hospital and they would not 
discharge her. You also say that the enrollee should not have to pay a bill where she is not able to be 
discharged. The Plan denied your request. The Plan says that the continued stay was not medically necessary. 
 
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. The Plan did not provide a copy of the applicable medical records for this case. 
Without this information we cannot determine that the Plan's coverage rules support the denial of payment in 
this case. Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we 
decided that the Plan has to pay for the continued inpatient stay provided from May 25, 2021, to May 26, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Corus CAD test provided on June 24, 2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this was not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the Corus CAD test is covered for the indications established in the 
applicable LCD. 
 
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 the testing. Our reviewer says that the requested testing was not medically reasona ble and 
necessary. Our physician reviewer found that the enrollee had no complaints of chest pain or an anginal equivalent. The Corus CAD 
test was not medically reasonable and necessary according to the coverage criteria established in the LCD. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the Corus CAD test provided 
on June 24, 2020.
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 ventilator. You say that you cannot be without a ventilator. The Plan 
denied your request. The Plan says the requested use of the device is not covered. 
 
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 ventilator. Our physician reviewer 
found that you have a diagnosis of asthma, very severe COPD, pulmonary hypertension, and sleep apnea. The 
available clinical records in the case file show you have used the noninvasive ventilator on only 6 out of 30 
nights, with an average of 1.9 hours per night. The documentation does not support that continued coverage of 
a portable ventilator is medically reasonable and necessary in this case.

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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the eyewear provided on February 2, 2021. 
 
You asked the Plan to pay more for the eyewear. You say that it has been at least three years since your last 
allowance. You say that you get $150 every two years, and the decision should be reviewed. The Plan denied 
your request. The Plan says the maximum allowance has been paid. 

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $150 for eyewear every 24 months. If the eyewear you purchase costs more 
than $150, you pay the difference. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
additional coverage of the eyewear have not been met. Specifically, the Plan paid the full $150 maximum 
allowance for the eyewear purchased on February 2, 2021, which exhausted your benefit. Therefore, we 
decided that the Plan does not have to pay more for the eyewear provided on February 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial-foot shoe insert (L5000).
You asked the Plan to pre-approve a partial-foot shoe insert. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested item have not been met.
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 partial-foot shoe insert. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that the insert at issue is requested to replace a previous insert to help the enrollee walk and prevent surgery. There was no planned or previous partial amputation documented. The records do not clearly show that the enrollee is effectively being treated for diabetes and monitored by the primary doctor on a regular basis to help control the diabetes. The requested partial foot prosthesis is not medically necessary as there is no previous or planned amputation, and there was insufficient documentation of current appropriate treatment to help control the enrollee's diabetes.
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 partial-foot shoe insert have not been met. Therefore, we decided that the Plan does not have to pre-approve a partial-foot shoe insert (L5000).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Abraxane, Pembrolizumab, Carboplatin, Palonosetron, Dexamethasone, and Keytruda.
You asked the Plan to pre-approve Abraxane, Pembrolizumab, Carboplatin, Palonosetron, Dexamethasone, and Keytruda. You say that the medications are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Abraxane, Pembrolizumab, Carboplatin, Palonosetron, Dexamethasone, and Keytruda. Our reviewer says that the medications are not medically necessary. Our physician reviewer found this is not a standard regimen for recurrent ovarian cancer. Use is not FDA approved or supported by the medical literature or major drug compendia. The tumor is not tumor mutational burden (TMB)-high or microsatellite instability (MSI)-high and immunotherapy has shown a poor response in ovarian cancer. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Abraxane, Pembrolizumab, Carboplatin, Palonosetron, Dexamethasone, and
Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Abraxane, Pembrolizumab, Carboplatin, Palonosetron, Dexamethasone, and Keytruda.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (97530) provided July 21, 2021. 
 
You asked the Plan to pay for the therapy services. You say that the therapy services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
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 CPT code 97530 is not supported in the medical record. Specifically, the services were rendered 
by a therapist in the home/hospice setting. There is a more appropriate CPT code to describe the billed service 
(G0152). Based on this information, we decided that Medicare rules for coverage of the therapy services have 
not been met. Therefore, we decided that the Plan does not have to pay for therapy services (97530) provided 
July 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the radiologic examination, chest (71046) 
provided April 30, 2021. 
 
You asked the Plan to waive the copayment for the diagnostic service. You say that due to the Plan delaying 
you having this medically necessary heart catherization, it caused you to have to have 2 sets of chest x-rays. 
You feel the Plan should cover for the first set of chest x-rays completed. The Plan denied your request. The 
Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage. 
 
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 $150 
copay for x-rays performed in an outpatient hospital facility. 
 
You have been asked to pay $69.36 for the diagnostic service. Since the allowed amount was less than the
copayment amount, you are responsible for the lesser amount. The diagnostic service 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 the radiologic examination, chest (71046) provided April 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ColoGuard testing rendered on May 19, 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 are not covered.
The Plan must follow Medicare rules. Medicare rules say that ColoGuard testing is covered when specific criteria are met. We looked at the file and Medicare rules. The file does not contain documentation to support that the criteria for coverage of ColoGuard testing are met. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the ColoGuard testing rendered on May 19, 2021.