Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walking boot (L4361) provided on June 21, 2021, by an 
out-of-network provider. 
 
You asked the Plan to pay for a walking boot. You say that the item at issue was a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for payment for out-of-network care have not been 
met. 
 
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 walking boot (L4361) provided on June 21, 
2021, by an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a physical therapy evaluation provided on 
October 13, 2021. 
 
You asked the Plan to waive the copayment for a physical therapy evaluation. You say that you only spoke to a 
physical therapist and nothing else. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct 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 $40 
copayment for each physical therapy visit and a $0 copayment for post-outpatient surgical procedure physical 
therapy consultations up to 15 minutes, prior to discharge.  
 You have been asked to pay a $40 copayment for a physical therapy evaluation. A physical therapy evaluation 
falls within the outpatient rehabilitation 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 a physical therapy evaluation provided on October 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 15, 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 July 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the portable oxygen concentrator purchased on 
September 23, 2021. 
 
You asked the Plan to reimburse you for the portable oxygen concentrator. You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the denial of payment 
for this item is correct because purchased oxygen equipment is not covered under Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for 
coverage and purchased oxygen equipment is statutorily non-covered. 
 
We looked at the file and Medicare rules. Purchased oxygen equipment is not covered. Therefore, we decided 
that the Plan does not have to reimburse you for the portable oxygen concentrator purchased on September 23, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 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 June 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on September 3, 
2021. 
 
You asked the Plan to pay for the durable medical equipment. 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. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for the durable medical equipment provided on September 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmological services: medical examination and 
evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established 
patient (92014) provided on November 30, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the medical eye exam. You say that the enrollee was referred for necessary 
services by her optometrist. The Plan denied your request. The Plan says these services were provided OON 
without prior authorization or referral from the enrollee's primary care provider. 
 
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 the ophthalmological services: medical 
examination and evaluation, with initiation or continuation of diagnostic and treatment program; 
comprehensive, established patient (92014) provided on November 30, 2021, by an out-of-network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Prodigy test strips, Prodigy control solution, and 
Sterilance lancets provided on May 12, 2020. 
 
You asked the Plan to pay for the non-preferred brand diabetic supplies. 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 medical necessity of non-preferred brand diabetic supplies. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred providers 
for durable medical equipment and supplies. 
 
We looked at the file, the Plan's contract and Medicare rules. The services at issue are diabetic supplies from a 
non-preferred brand. The services are available from the Plan's preferred brand. There was no documentation 
provided to support the medical necessity of non-preferred brand supplies. Therefore, we decided that the Plan 
does not have to pay for the Prodigy test strips, Prodigy control solution, and Sterilance lancets provided on 
May 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the portable oxygen concentrator purchased on 
August 30, 2021. 
 
You asked the Plan to reimburse you for the portable oxygen concentrator. You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the denial of payment 
for this item is correct because purchased oxygen equipment is statutorily non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for 
coverage and purchased oxygen equipment is statutorily non-covered.  
 
We looked at the file and Medicare rules. Purchased oxygen equipment is not covered. Therefore, we decided 
that the Plan does not have to reimburse you for the portable oxygen concentrator purchased on August 30, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facet joint ablation procedure (64635, 64636). 
 
You asked the Plan to pre-approve the facet joint ablation procedure. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that repeat thermal facet joint radiofrequency ablation at 
the same anatomic site is considered medically reasonable and necessary provided the patient had a minimum 
of consistent 50% improvement in pain for at least six (6) months or at least 50% consistent improvement in 
the ability to perform previously painful movements. 
 
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 facet joint ablation procedure. Our 
reviewer says that the procedure is not medically necessary. Our physician reviewer found the original ablation 
procedure did not provide sustained relief and there are 2 separate probable pain generators that have not been 
addressed. 
 
 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 facet joint ablation procedure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a facet joint ablation procedure (64635, 64636).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Hyperthermia treatment (77600-59-XU) provided on 
August 31, 2021. 
 
You asked the Plan to pay for code 77600-59-XU. 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 providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the provider reported 2 modifiers for the same procedure 
code.  Procedures codes should not be reported with XU and 59 for the same procedure code. Therefore, we 
decided that the Plan does not have to pay for the Hyperthermia treatment (77600-59-XU) provided on August 
31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder arthroscopy (29822) provided on October 19, 
2021. 
  You asked the Plan to pay for the shoulder arthroscopy (29822). The Plan denied your request. The Plan says 
CPT code 29822 is considered inclusive to CPT code 29827. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 shoulder arthroscopy (29822) Our 
reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our 
physician reviewer found that the documentation does not support shoulder arthroscopy repair, the surgical 
report documents a right-hand index trigger finger release. 
 
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 shoulder arthroscopy (29822) have not been met. Therefore, we decided that 
the Plan does not have to pay for the shoulder arthroscopy (29822) provided on October 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Gelsyn-3 joint injections provided from 
July 21, 2021, to August 4, 2021. 
 
You asked the Plan to waive the coinsurance for the injections. You say that the provider did not inform you of 
any copayments for the injections. 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 Part B drugs, including pain management drugs. 
 
 
 Drug Allowed Amount 20% Coinsurance 
Gelsyn-3 Injection  July 21, 2021 $1,008.00 $201.60 
Gelsyn-3 Injection  July 28, 2021 $1,008.00 $201.60 
Gelsyn-3 Injection  August 4, 2021 $1,008.00 $201.60 
Total:  $604.80 
 
You have been asked to pay $604.80, which is 20% of the allowed amount for the injections. The injections fall 
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 waive the 
coinsurance for Gelsyn-3 joint injections provided from July 21, 2021, to August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on September 30, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the home visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the home visit provided on September 30, 2021, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit on November 9, 2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that you should not have to pay the 
copay because there was no service performed but that the provider just suggested rehabilitation. 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 $25 
copay for office visits to specialists at an independent office. 
 
 
 
 You have been asked to pay a $25 copay for the office visit. The 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 the office visit on November 9, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the assistant at surgery services provided on March 1, 2021. 
 
You asked the Plan to pay for the assistant at surgery services. 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. In this case, the Plan denied payment for the assistant surgery services because 
the AS modifier was not reported in the first modifier position. However, the Plan failed to provide any 
evidence showing that this claim is not payable when the AS modifier is not reported in the first modifier 
position. Therefore, we decided that the Plan has to pay for the assistant at surgery services provided on March 
1, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional level of transforaminal epidural injection 
(64484) billed for date of service May 18, 2021. 
 
You asked the Plan to pay for an additional level of transforaminal epidural injection. You say that you have 
submitted records to support the procedure. The Plan denied your request. The Plan says the provided records 
do not support the service 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. 
 
In this case, the CPT Code Manual definition of code 64484 is "Injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional level 
(List separately in addition to code for primary procedure)." 
 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 an additional level of transforaminal epidural injection. Our 
reviewer says that the billed code does not meet criteria for payment. Our reviewer found that the records do 
not show that an additional level of the spine was injected. The documentation does not support the procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an additional level of transforaminal epidural injection have not been met. 
Therefore, we decided that the Plan does not have to pay for an additional level of transforaminal epidural 
injection (64484) billed for date of service May 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code 81405, 81406, 81404, 
81403) provided on September 15, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the ordering provider is not the treating provider. 
 
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 laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation indicates that the obtained laboratory studies: the laboratory 
services (CPT code(s): 81405, 81406, 81404, 81403) provided on September 15, 2020, were ordered solely for 
screening purposes. The laboratory studies were not medically necessary and reasonable. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (CPT code 81405, 81406, 81404, 81403) provided on 
September 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the low osmolar contrast material (Q9967) provided on 
October 11, 2021. 
 
You asked the Plan to pay for the low osmolar contrast material (Q9967). You say that additional medical 
records are attached, and the claim should be reprocessed. The Plan denied your request. The Plan says the 
documentation does not include the dosage administered, which is required to support the billed code and units. 
 
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 Q9967 is low osmolar contrast material, 300-399 mg/ml 
iodine concentration, per ml. 
 
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 low osmolar contrast material (Q9967). Our reviewer 
says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer 
found that the procedure report does not document the dosage given. Therefore, 50 units/50 ml cannot be 
confirmed. 
 
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 low osmolar contrast material (Q9967) have not been met. Therefore, we 
decided that the Plan does not have to pay for the low osmolar contrast material (Q9967) provided on October 
11, 2021.