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

 
We decided that the Plan does not have to waive the copayments for outpatient mental health services from 
October 22, 2021 to November 23, 2021 
 
You asked the Plan to waive the copayments for outpatient mental health services. You say that you are 
requesting reconsideration of two claims The Plan denied your request. The Plan says the copayments applied are 
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 $100 
copayment for outpatient mental health services. The total cost share amount is $290.78. 
 
You have been asked to pay a $100 copayment for outpatient mental health services. Outpatient mental health 
care services falls within the Outpatient mental health care benefit category. The records show the bill was for outpatient mental health services. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for outpatient mental 
health services from October 22, 2021 to November 23, 2021
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81225, 81226, 81227, 81230, 81231, 81232, 
81240, 81241, 81283, 81328, 81335, 81350, 81355, 81381) provided November 15, 2021. 
 
You asked the Plan to pay for the lab services. You say that these 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 if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code. If no CPT code accurately describes the procedure performed, the 
laboratory may report CPT code 81479. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were billed for a single test panel. Based 
on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services (81225, 81226, 81227, 81230, 81231, 
81232, 81240, 81241, 81283, 81328, 81335, 81350, 81355, 81381) provided November 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prolotherapy and electrical stimulation treatment (96372, 
97016, 97112, 97139, J3411, J3415, J3490, J7999) provided October 26, 2021. 
 
You asked the Plan to pay for the prolotherapy and electrical stimulation treatment. You say that this procedure 
was medically necessary. The Plan denied your request. The Plan says this service is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that  Medicare does not cover Prolotherapy. Its 
billing under the trigger point injection code is a misrepresentation of the actual service rendered. 
 
We looked at the file and Medicare rules. This service is non-covered under Medicare. Based on this 
information, we decided that Medicare rules for coverage of the prolotherapy and electrical stimulation 
treatment have not been met. Therefore, we decided that the Plan does not have to pay for prolotherapy and 
electrical stimulation treatment (96372, 97016, 97112, 97139, J3411, J3415, J3490, J7999) provided October 
26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88311, 88305) provided February 18, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the codes billed are 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. 
 
We find that CPT code 88311 & 88305 is not supported in the medical record. Specifically, these procedures 
are inclusive to the primary procedure and are not separately billable. Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for lab services (88311, 88305) provided February 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a TheraSkin application (Q4121) provided October 12, 2021 
to October 21, 2021. 
 
You asked the Plan to pay for the TheraSkin application. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 Q4121 is TheraSkin, per square centimeter. 
 
We find that CPT code Q4121 is not supported in the medical record. Specifically, 39 units were billed, 
however the records do not note the measurement unit applied. Based on this information, we decided that 
Medicare rules for coverage of the TheraSkin application have not been met. Therefore, we decided that the 
Plan does not have to pay for a TheraSkin application (Q4121) provided October 12, 2021 to October 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MYOPRO Motion G device. 
 
You asked the Plan to pre-approve MYOPRO Motion G device. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria 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 MYOPRO Motion G device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found although records from the device manufacturer/vendor argue medical 
necessity of the requested device, no records from the enrollees actual treating provider clarify why the 
requested device is the most appropriate treatment for the enrollees condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MYOPRO Motion G device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve MYOPRO Motion G device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (75726) provided August 10, 2021. 
 
You asked the Plan to pay for the radiology services. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the code billed 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. 
 
We find that CPT code 75726 is not supported in the medical record. Specifically, CPT 75726 is included in 
CPT 37243 which was also billed. Based on this information, we decided that Medicare rules for coverage of 
the radiology services have not been met. Therefore, we decided that the Plan does not have to pay for 
radiology services (75726) provided August 10, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99283) provided October 2, 2021. 
 
You asked the Plan to pay for the emergency room services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the claim did not include a valid diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99283 is not supported in the medical record. Specifically, diagnosis code R18.0 is a 
secondary only diagnosis code. No primary diagnosis code was included. Based on this information, we 
decided that Medicare rules for coverage of the emergency room services have not been met. Therefore, we 
decided that the Plan does not have to pay for emergency room services (99283) provided October 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided from July 29, 2021, to 
August 27, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 
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 outpatient services provided from July 29, 
2021, to August 27, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a myocardial perfusion imaging (SPECT) 
test and dipyridamole injection (78452, J1245) provided on December 20, 2021. 
 
You asked the Plan to waive the copayment for the SPECT test and dipyridamole injection. You say that the 
services should be covered as you disagree with the charges. The Plan denied your request. The Plan says the 
cost-sharing applied correctly based on the services provided. 
 
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 $100 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies and a 20% coinsurance for 
Part B medications and contrast agents injected during the service.  
You have been asked to pay a $100 copayment for the SPECT test and a 20% coinsurance for the dipyridamole 
injection (allowed is $21.90 x 20% = $4.38). SPECT tests and dipyridamole injections fall within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies and Part B medications service 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 myocardial perfusion imaging (SPECT) test 
and dipyridamole injection (78452, J1245) provided on December 20, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the circulation screening on October 19, 
2021. 
 
You asked the Plan to waive the copayment for the circulation screening. You say that you did not want this 
service done. 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 $110 
copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a 
physicians office.  
 
 You have been asked to pay a $108.42 copayment for the circulation screening, which is less than the $110 
copayment. The circulation screening 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 circulation screening 
on October 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a 3D image rendering and interpretation (76376) provided 
June 22, 2021. 
 
You asked the Plan to pay for the 3D image rendering and interpretation. You say that the service was 
medically necessary. The Plan denied your request. The Plan says the code billed is not eligible for separate 
payment. 
 
The Plan must follow Medicare rules. Medicare rules say that 3D-rendering with interpretation is integral to the 
primary surgical procedure and not a separately reimbursed service. 
 
We looked at the file and Medicare rules. This procedure is not separately reimbursed. Based on this 
information, we decided that Medicare rules for coverage of the 3D image rendering and interpretation have 
not been met. Therefore, we decided that the Plan does not have to pay for a 3D image rendering and 
interpretation (76376) provided June 22, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that the medication is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria.  The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Injectafer. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the enrollee has tried and failed Venofer 
but based on the medical records provided there is no indication that Infed would likely be less effective and/or 
likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for percutaneous vertebral augmentation 
provided on February 24, 2021. 
 
You asked the Plan to waive the cost share for the percutaneous vertebral augmentation. You say that you had 
to have this procedure done after breaking your back in January. 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). The Plan contract says that there is a $1,000 deductible which 
applies to certain items and services. The Plan deductible applies to out-of-network outpatient surgery at an 
ambulatory surgical center. Your contract with the Plan also clearly says that you must pay 30% coinsurance 
for out-of-network outpatient surgery at an ambulatory surgical center. 
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
total of $1,212.74 for the percutaneous vertebral augmentation on February 24, 2021. The deductible was not 
met at the time of service; therefore, $362.58 was applied to satisfy the remainder of the deductible. The Plan 
has followed Medicare rules by clearly disclosing in the contract that there is $1,000 deductible which applies 
to outpatient surgery at an ambulatory surgical center. This cost sharing is a contractual obligation that had not 
been met at the time the percutaneous vertebral augmentation was received on February 24, 2021.  
 
The allowed amount remaining after you paid your deductible is $2,833.88 ($3,196.46 original allowed amount 
- $362.58 deductible paid = $2,833.88 remaining allowed amount). You have been asked to pay $850.16, 
which is 30% of the remaining allowed amount for the percutaneous vertebral augmentation ($2,833.88 
remaining allowed amount x 30% coinsurance = $850.16). Percutaneous vertebral augmentation 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 cost share for percutaneous vertebral 
augmentation provided on February 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0482) provided July 20, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
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 lab 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 lab services (G0482) provided July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Viberzi. 
 
You asked the Plan to pre-approve Viberzi. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Viberzi.  
 
Benefits for Viberzi 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you received oral medications, had stable vital 
signs and your lungs were clear. You were at a supervision level for functional mobility including mobility in 
your power WC to 300 feet. You do not require skilled nursing or therapy services on a daily basis. You do not 
meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections (96379, 97139, J1955, J3411, J3415, J3490, 
J7999) provided July 29, 2021. 
 
You asked the Plan to pay for the injections. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the codes billed cannot be separately paid. 
 
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 codes 96379, 97139, J1955, J3411, J3415, J3490, & J7999 are not supported in the medical 
record. Specifically, the individual drugs within a compounded mixture are not separately billable. Based on 
this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, 
we decided that the Plan does not have to pay for injections (96379, 97139, J1955, J3411, J3415, J3490, J7999) 
provided July 29, 2021.