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

 
We decided that the Plan does not have to waive the coinsurance for a Orthovisc (hyaluronan) injection 
provided on November 4, 2021. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you were never told that there was a 
copayment for this. You also say that you had a series of three shots and cannot afford a bill for $180. 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 20% 
coinsurance for Part B drugs.  
 You have been asked to pay $59.50, which is 20% of the allowed amount for an injection ($297.48 allowed 
amount x 20% coinsurance = $59.50). An injection 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 a Orthovisc (hyaluronan) injection provided 
on November 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for ostomy supplies provided on January 12, 
2022. 
 
You asked the Plan to waive the coinsurance for ostomy supplies. You say that you were told that these 
supplies would be included in the visiting nurse's home visit. The Plan denied your request. The Plan says the 
coinsurance amount you are being charged 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 in-network ostomy supplies. The allowed amount of these supplies is $276.70, resulting in a 
coinsurance amount of $55.34. 
 
You have been asked to pay 20% coinsurance for ostomy supplies. Ostomy supplies fall within the Prosthetic 
Devices and Related Supplies benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for ostomy 
supplies provided on January 12, 2022.  
 
Your complaint about receiving inaccurate information about the cost-share for these supplies is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on October 1, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that you would like the claim processed for 
payment. The Plan denied your request. The Plan says the rendering provider is an out-of-network provider and 
there was no referral from an in-network provider or an approved authorization. Also, the service rendered was 
not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a home health visit provided on October 1, 2021, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Domiciliary services provided on October 6, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Domiciliary services. You say that that it isn't your responsibility to obtain prior 
authorization. The Plan denied your request. The Plan says prior authorization is required for an out-of-network 
visit. 
 
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 Domiciliary services provided on October 6, 2021 
by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Ondansetron tablet. 
 
You asked the Plan to pre-approve Ondansetron. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B for the enrollee's clinical situation. Therefore, we decided that the Plan does not have to pre-
approve treatment with Ondansetron tablet.  
 
Benefits for Ondansetron may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this is medically reasonable and 
necessary. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
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 the Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental. More research is needed before coverage can be 
approved. 
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the revascularization (37224) provided on September 27, 
2021. 
 
You asked the Plan to pay for the revascularization (37224). You say that the medical records submitted 
warrant payment for services performed as this procedure was medically necessary based on the patients 
history. You say that the medical records should be reviewed as the services were appropriately billed. The 
Plan denied your request. The Plan says procedure code 37224 is not supported by the medical records 
submitted. 
 
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 37224 is revascularization, endovascular, open or 
percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty. 
 
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 revascularization (37224). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found the 
operative report describes this procedure was unsuccessful with multiple attempts. In, this case, CPT 37224 is 
inappropriate to report, as this procedure was not performed. 
 
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 revascularization (37224) have not been met. Therefore, we decided that the 
Plan does not have to pay for the revascularization (37224) provided on September 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 29, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the provider is enrolled and an in-network provider 
with the Plan. Therefore, the services are payable. The Plan denied your request. The Plan says the rendering 
provider is an out-of-network provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on November 29, 2021, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre sensor. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for continuous 
glucose monitors and related supplies have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this 
information, we decided that Medicare rules for coverage of a Freestyle Libre sensor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor 
sensor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81404, 81405, and 81406) provided 
on January 5, 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. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services (81404, 81405, and 81406) provided on January 5, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) provided on 
December 20, 2021. 
 
You asked the Plan to pay for the CGM. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the enrollee enrolled in hospice from November 12, 
2021, to February 9, 2022. The Plan says, per Medicare guidelines, the provider needs to bill Original Medicare 
for the services provided on December 20, 2021. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) provided on 
December 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 13, 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 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DecisionDx Melanoma testing. 
 
You asked the Plan to pay for DecisionDx Melanoma testing. You say that you would like reconsideration 
because this testing is a Medicare covered benefit. The Plan denied your request. The Plan says this testing was 
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 DecisionDx Melanoma testing. Our reviewer 
says that it was found that the provided information does not satisify the LCD requirements. Our physician 
reviewer found the enrollee does not have a personal history of melanoma with Stage T1b and above or T1a 
with documented concern about adequacy of microstaging. The enrollee is not undergoing workup or being 
evaluated for treatment. The enrollee does not have metastatic disease and does not have a presumed risk for a 
positive Sentinel Lymph Node Biopsy (SLNB) based on clinical, histological, or other information. The 
enrollee does not have a disease stage, grade, and Breslow thickness (or other qualifying conditions) within the 
intended use of the test. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of DecisionDx Melanoma testing have not been met. Therefore, we decided that 
the Plan does not have to pay for DecisionDx Melanoma testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an Orthovisc injection on October 28, 
2021. 
 
You asked the Plan to waive the coinsurance for an Orthovisc injection. You say that you were never told there 
was a copayment for this. The Plan denied your request. The Plan says there is a 20% coinsurance owed by the 
enrollee per the 2021 EOC. 
 
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 An Orthovisc injection. The allowed amount of the injection is $297.48, resulting in a 
coinsurance amount of $59.50. 
 
You have been asked to pay 20% coinsurance for an Orthovisc injection. An Orthovisc injection 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 an Orthovisc injection on October 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Omnipod insulin pods. 
 
You asked the Plan to pre-approve the Omnipod insulin pods. You say that the Omnipods are medically 
necessary. The Plan denied your request. The Plan says this item is not eligible for coverage under the Part B 
medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Omnipod insulin pods.  
 
Benefits for the Omnipod insulin pods may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Therapeutic procedure provided on June 24, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Therapeutic procedure. You say that you would like to request reconsideration 
for payment. The Plan denied your request. The Plan says prior authorization is required for an out-of-network 
visit. 
 
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 Therapeutic procedure provided on June 24, 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 an inpatient hospital stay provided from 
November 1, 2021, to November 8, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you would like the Plan 
to relook at the claim. The Plan denied your request. The Plan says the proper copayment was applied for the 
service that was rendered. 
  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 $315 
copayment per day for Days 1-7 for each Medicare-covered hospital stay. From November 1, 2021, to 
November 8, 2021, there was a total of 8 days in the inpatient hospital with only 7 days being charged a 
copayment since the 8
th
 day was the date of discharge. The total copayment amount charged for the inpatient 
hospital stay was $2,205 ($315 copayment per day x 7 days). 
 
You have been asked to pay a $2,205 copayment 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 
an inpatient hospital stay provided from November 1, 2021, to November 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services (99190, 99191, 86891, and P9022) 
provided on July 8, 2021. 
 
You asked the Plan to pay for codes 99190, 99191, 86891, and P9022. 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. Medicare does not pay any provider or supplier other than the facility or 
hospital for services furnished to the beneficiary while an inpatient.  
 
We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during 
an inpatient hospitalization. Payment for these services were included in the facility payment. Therefore, we 
decided that the Plan does not have to pay for the medical services (99190, 99191, 86891, and P9022) provided 
on July 8, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for a gadobutrol injection provided on November 19, 
2021. 
 
You asked the Plan to waive the coinsurance for a gadobutrol injection. You say that you already paid the $110 
copayment for the diagnostic magnetic resonance imaging (MRI), which is what you have paid for them in the 
past. You also say you do not believe you owe more. The Plan denied your request. The Plan says that 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.  
 
The Plan says you must pay $18, which is 20% coinsurance for a gadobutrol injection. According to Medicare, 
a gadobutol injection is packaged into payment for other services. Therefore, it is not separately payable. We 
decided that the Plan has to waive the coinsurance for a gadobutrol injection provided on November 19, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.