Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for certain injections. We decided that the Plan does not 
have to waive the coinsurance for certain injections.  
 
You asked the Plan to waive the coinsurance for the injections. You say that you asked the doctor to consider 
the lower cost chemotherapy generic medications. The Plan says that you have been charged the correct 
coinsurance amount. 
 
We decided that the Plan has to waive the coinsurance for the injections provided on January 3, 2022 
and January 18, 2022. 
 
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 Explanation of Benefits (EOB) applicable 
to dates of service January 3, 2022 and January 18, 2022. Without the applicable EOB, we cannot determine 
whether the 20% in-network coinsurance that you have been asked is correct based on your contract with the 
Plan. Therefore, the Plan has not shown that its decision to ask you to pay the 20% coinsurance for these 
injections is correct or justified according to Medicare rules and the Plan contract. Therefore, we decided that 
the Plan has to waive the copayment for the injections provided on January 3, 2022 and January 18, 2022.  
 
We also decided that the Plan does not have to waive the coinsurance for the injections provided on 
September 28, 2021, October 11, 2021 and January 31, 2022. 
 
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 20% 
coinsurance for each Medicare-covered Part B drug. Therefore, we decided that the Plan does not have to 
waive the coinsurance for certain injections. 
 
The allowed amounts of these injections total $16052.69. You have been asked to pay a total of $2572.42. 
 
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 the genicular nerve block rendered on August 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 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 these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has chronic knee pain due to 
osteoarthritis. Heat and physical therapy reduced the pain. He underwent a genicular nerve block. The 
procedure is considered experimental/investigational in nature and is the subject of ongoing clinical trials.  Its role in the management of knee osteoarthritis is uncertain. The services were therefore not reasonable or 
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 genicular nerve block rendered on August 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the requested epidural steroid 
injection is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested epidural steroid injection. 
 
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 epidural steroid injection. Our 
reviewer says that the enrollee does not meet criteria for the requested epidural steroid injection. Our physician 
reviewer found the clinical documentation provided shows the 1
st
 epidural steroid injection (ESI) done on 
February 23, 2022, provided 50% relief and the 2
nd
 ESI done on April 8, 2022, provided 20% pain relief.  The 
review has determined that the enrollee does not meet the LCD criteria for the requested 3
rd
 epidural steroid 
injection. 
 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 epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tempus gene Panel testing coded as 81275, 81276, 71301, 
81292, 81295, 81298, 81317, 81404, 81162, 81191 and 81206 provided October 3, 2021. 
 
You asked the Plan to pay for Tempus gene Panel testing. You say that based on the information provided, you 
request for reconsideration of the determination and coverage of the Tempus Gene Panel test at the in-network 
benefit level. The Plan denied your request. The Plan says CPT codes 81275, 81276, 71301, 81292, 81295, 
81298, 81317, 81404, 81162, 81191 are not medically necessary and 81206 denied for coding error and not 
being FDA approved. 
 
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 Tempus gene Panel testing. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is a 73 year old female with locally advanced pancreatic cancer. Clinical 
notes from August 2021 state she is responding and tolerating treatment well. The review has determined that 
the medical records provided do not meet the requirements listed in the NCD for Medicare coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tempus gene Panel testing have not been met. Therefore, we decided that the 
Plan does not have to pay for Tempus gene Panel testing coded as 81275, 81276, 71301, 81292, 81295, 81298, 
81317, 81404, 81162, 81191 and 81206 provided October 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator, single delivery port (E1390) and 
oxygen accessory, battery pack/cartridge for portable concentrator (E1356) purchased December 7, 2021. 
 
You asked the Plan to pay for the oxygen equipment. You say that you have submitted all of the paperwork to 
support the need for the machine as well as paperwork supplied by the Plan for a claim to be filed. The Plan 
denied your request. The Plan says per Medicare guidance, oxygen equipment is only covered when rental. 
Purchased oxygen equipment is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare covers the rental of oxygen equipment and accessories as durable medical 
equipment that your doctor prescribes for use in your home. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the oxygen equipment have not been met. Therefore, we decided that the Plan does not have to pay 
for the oxygen concentrator, single delivery port (E1390) and oxygen accessory, battery pack/cartridge for 
portable concentrator (E1356) purchased December 7, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrophysiologic 3D mapping (93613) provided on 
December 14, 2021. 
 
You asked the Plan to pay for electrophysiologic mapping. You say that this service is appropriate as billed and 
is supported in the record. The Plan denied your request. The Plan says this is an add-on code and cannot be 
paid as it was not billed/performed with an appropriate primary procedure. 
 
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 
electrophysiologic mapping is an add-on code and has not been billed with an appropriate primary procedure 
code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the 
Plan does not have to pay for electrophysiologic 3D mapping (93613) provided on December 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids. 
 
You asked the Plan to pre-approve hearing aids. The Plan denied your request. The Plan says the Health Plan 
and Medicare do not cover hearing aids. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related 
services.  
 
Though hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these 
types of items and services. Therefore, we decided that the Plan does not have to pre-approve hearing aids.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99285) provided on January 4, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the MUE has been 
exceeded.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 99285 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. 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 the services (99285) 
provided on January 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the food delivery program. 
 
You asked the Plan to pre-approve the food delivery program. The Plan denied your request. The Plan says in 
order for you to receive this service, certain criteria must be met. You must have both high blood sugar 
(diabetes) and a condition that affects how you feel (depression). The information received shows that you are 
treated for depression. You do not have diabetes. Based on the policy, both conditions are required for this 
service to be medically necessary 
 
The Plan contract covers a supplemental Grocery Benefit. The Plan benefit says members must be diagnosed 
with both Diabetes and Depression to be eligible to receive the grocery benefit from a Plan-specified vendor. 
 
We looked at the file and Medicare rules. The file shows that you do not have both Diabetes and Depression as 
conditions that are required for the grocery benefit. Based on this information, we decided that the Plans rules 
for coverage of the food delivery program have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the food delivery program.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiofrequency ablation, nerves innervating the sacroiliac 
joint, with imaging guidance (Fluoroscopic or Computed Tomography (64625) provided September 22, 2021. 
 
You asked the Plan to pay for the surgical procedure. You say that the first part of her care (1st block) was 
under a different insurance. The 2nd block and final RFA is now under the Plan and should be covered as 
continued care. The Plan denied your request. The Plan says radiofrequency ablation for sacro-iliac joint pain is 
considered not medically necessary and investigational whether performed using traditional, cooled or pulsed 
radiofrequency. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the surgical procedure have not been met. Therefore, we decided that the Plan does not have to pay 
for the radiofrequency ablation, nerves innervating the sacroiliac joint, with imaging guidance (Fluoroscopic or 
Computed Tomography (64625) provided September 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there is little evidence in the medical literature to suggest that this 
is an appropriate procedure for the enrollee's back pain. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The Intracept is 
experimental. More research is needed. Our physician reviewer found that the enrollee's condition does not 
meet criteria for these services. 
 
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 pre-approve the Intracept procedure for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100). 
 
You asked the Plan to pre-approve additional transportation. You say that you do not have family to take you to 
treatments. You say that if you do not have transportation, you cannot receive treatments. You also say that you 
need additional trips to be approved. The Plan denied your request. The Plan says the transportation benefit has 
been exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 6 one-way trips per year.   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100).
Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to pay for the tomosynthesis. We decided that the Plan does not have to pay for 
the ultrasounds.  
 
You asked the Plan to pay for tomosynthesis and ultrasounds. You say that these services were billed 
appropriately and are supported in the medical record. The Plan says that codes 76641-LT and 76641-RT are 
duplicate claim lines from previously paid claims. Code G0279 is an add-on code, and while it was billed with 
an appropriate primary procedure (77066), this primary procedure is not supported in the record and was 
denied in a separate case. 
 
We decided that the Plan has to pay for the tomosynthesis.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that an add-on code is eligible for payment only if it is reported with an appropriate primary 
procedure performed by the same practitioner 
 
The Plan denied payment of G0279 on the basis that code 77066 was also denied. We received the Plans 
denial of 77066 in a separate appeal and found that 77066 was denied erroneously and should be paid. Because 
77066 is supported in the record and has been approved for payment, this means that the Plans denial of 
G0279 is no longer substantiated. Based on the claim submitted, Medicare billing criteria have been met. 
Therefore, we decided that the Plan has to pay for the tomosynthesis (G0279) provided on September 21, 2021. 
 
We also decided that the Plan does not have to pay for the ultrasounds. 
 
The rules say that claims or claim lines that have been determined to be an exact duplicate are rejected and do 
not have appeal rights. 
 
The documentation shows that claim lines for 76641-RT and 76641-LT were previously submitted to the Plan 
and paid. These previously paid claims were submitted with the same date, same CPT code and modifiers, by 
the same provider for the same enrollee. There is no documentation to show that the enrollee received these 
same services twice on the date in question. Therefore, we decided that the Plan does not have to pay for the 
ultrasounds (76641-RT and 76641-LT) provided on September 21, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cataract surgery of the left eye on January 
19, 2022. 
 
You asked the Plan to waive the copayment for cataract surgery. You say that you had this procedure done in 
2021 and cannot afford to pay for it again in 2022. The Plan denied your request. The Plan says the copay 
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 $250 
copayment for cataract surgery at an ambulatory surgical center. 
 
You have been asked to pay $250 copayment for 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 copayment for cataract surgery of the left eye on January 19, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 11, 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 billed correctly. 
 
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 these 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 rendered on February 11, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility (SNF) stay 
provided from January 1, 2022, to January 14, 2022. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you were unaware that this would be 
part of the same benefit as a previous SNF stay in November 2021. 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 $0 
copayment for days 1-20 for a skilled nursing facility stay. The contract also says there is a $188 copayment per day for days 21-100. The contract says a benefit period begins the day you go into a skilled nursing facility. 
The benefit period ends when you havent received any inpatient hospital care (or skilled care in a SNF) for 60 
days in a row. 
 
According to the EOC, a benefit period ends when you have not received inpatient or SNF care for days in a 
row. You are not being charged for the first 20 days you were in the SNF during this benefit period from 
October 26, 2021, to November 12, 2021, and from December 29, 2021, to December 31, 2021. You have been 
asked to pay a total of $2,576, which is less than the $188 copayment per day for days 21-100 for a SNF stay 
from January 1, 2022, to January 14, 2022. A SNF stay falls within the Skilled Nursing Facility (SNF) 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 a skilled nursing facility (SNF) 
stay provided from January 1, 2022, to January 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for in-network Part B prescription drugs on 
February 3, 2022. 
 
You asked the Plan to waive the coinsurance for in-network Part B prescription drugs. You say that you did not 
think you had any copays for in-network services. The Plan denied your request. The Plan says the coinsurance 
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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay $78.29 which is the 20% coinsurance for in-network Part B prescription drugs. In-
network Part B prescription drugs 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 waive the coinsurance for in-network Part B prescription drugs on February 3, 2022.