Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate 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 the clinical value and effectiveness of bone marrow aspirate in the 
setting of spinal fusion surgery has not been demonstrated in the peer-reviewed literature. 
 
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. There is limited 
published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe 
treatment for the noted pathology. There is no specific indication provided to support the request for bone 
marrow aspirate for the approved surgery. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception to guidelines. Our 
physician reviewer found that the enrollee's condition does not meet criteria for coverage of 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 bone marrow aspirate for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye specialist visit provided on 
November 2, 2021. 
 
You asked the Plan to waive the copayment for the eye specialist visit. You say that you should only have a 
$10 copayment for the exam. You say that there was no specialist involved. 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 a $20 
copayment for eye specialist visits.  
You have been asked to pay a $20 copayment for the eye specialist visit. The eye specialist visit falls within the 
Vision 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 eye specialist visit 
provided on November 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the second intraoral x-ray (D0230) provided on March 22, 
2021, and the intraoral x-ray (D0220), core buildup (D2950) and crown (D2740) provided on June 16, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were led to believe you had $2,000 of 
dental coverage for the year, and never would have had this work done if you realized it was only a $1,000 
limit. The Plan denied your request. The Plan says you have met and exceeded your annual $1,000 limit for 
covered dental services, and you are responsible for the remaining charges. This information was included in 
the 2021 Annual Notice of Changes. In addition, your benefit covers a maximum of one intraoral x-ray per year. 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, items or services provided in excess of 
the Plan's $1,000 annual maximum are not covered under this benefit and are the responsibility of the enrollee. 
Therefore, we decided that the Plan does not have to pay for the second intraoral x-ray (D0230) provided on 
March 22, 2021, and the intraoral x-ray (D0220), core buildup (D2950) and crown (D2740) provided on June 
16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on December 8, 2021 by an out-
of-network (OON) Psychiatrist. 
 
You asked the Plan to pay for telehealth services. You say that this facility is in-network with the Plan. The 
Plan denied your request. The Plan says the facility is in-network, however the treating physician is out-of-
network with the Plan. Therefore, the services were provided out-of-network and were not approved in 
advance. 
 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 telehealth services provided on December 8, 2021 
by an out-of-network (OON) Psychiatrist.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for cardiac catheterization provided on 
December 1, 2021. 
 
You asked the Plan to waive the coinsurance for outpatient surgery. You say that this amount is not 
commensurate with cost-sharing you have been charged before, and you are requesting any relief from this 
charge. 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 4% 
coinsurance for in-network outpatient surgery at an outpatient hospital facility, up to an in-network maximum 
out-of-pocket amount of $1,500 for 2021. At the time this claim was processed, $739.58 of the $1,500 in-
network maximum out-of-pocket amount had been met.  The allowed amount of this claim is $20,704.57, resulting in a coinsurance amount of $760.42 because this 
amount meets the $1,500 maximum out-of-pocket amount for 2021. 
 
You have been asked to pay 4% coinsurance for outpatient surgery. Outpatient 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 coinsurance for cardiac catheterization 
provided on December 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99215) and the  
electrocardiogram (93000) provided on June 7, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
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 $15 
copayment for each out-of-network Medicare-covered primary care doctor visit.    
 
 
 You have been asked to pay a $15 copayment for the out-of-network Medicare-covered primary care doctor 
visit provided. The Plan previously reprocessed this claim to adjust the copayment from $30 to $15. 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 (99215) and the  electrocardiogram (93000) 
provided on June 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tempus xT Heme Testing provided to the enrollee on 
September 28, 2021. 
 
You asked the Plan to pay for the testing. You say that this was medically necessary. The Plan denied your 
request. The Plan says a review of the medical literature and clinical practice guidelines does not support the 
clinical utility of broad genomic profiling for an hematological malignancy to direct therapeutic management. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case.  
 
 Our physician reviewer found while multiple studies have demonstrated the utility of NGS-based MRD assays 
to predict clinical outcome, it remains unclear whether therapeutic intervention based on these data will 
ultimately change patient outcomes and result in increased overall survival. It also remains unclear exactly 
what level of mutation clearance is required (i.e., VAF) to determine whether a patient should be deemed MRD 
negative and how issues surrounding persistent clonal hematopoesis should be resolved. Future clinical trials 
will be required to evaluate the effects of early therapeutic intervention based on MRD positive post-treatment 
findings. The review has determined that the services at issue in this case are not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for Tempus xT Heme Testing provided to the enrollee on September 28, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response/treatment with no transport (A0998) 
provided on December 21, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 21, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response/treatment with no 
transport (A0998) provided on December 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breathing capacity tests (94010 x 2) rendered by the out-
of-network (OON) provider on August 3, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services was rendered by an out of 
network provider, without prior authorization. 
 
 
 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the breathing capacity tests (94010 x 2) rendered by the out-of-network (OON) 
provider on August 3, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the moderate sedation services and emergency room (ER) services 
rendered on April 25, 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 that we will not pay codes 99152 and 99285. 
 
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 states that they will not pay codes 99152 and 99285 but has not 
provided any documentation or Medicare rules to support that the codes are not payable as billed. Therefore, 
we decided that the Plan has to pay for the moderate sedation services and emergency room (ER) services 
rendered on April 25, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on December 
29, 2021. 
 
You asked the Plan to pay for the services. You say that the enrollee required a stretcher due to dependence on 
supplemental oxygen. The Plan denied your request. The Plan says the medical documentation does not 
substantiate the medical necessity requirements. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were medically reasonable and necessary. Our physician reviewer found the record 
indicates that the enrollee was transported to a rehabilitation facility  using nasal cannula oxygen. The record 
indicates that the enrollee was transported via stretcher. The record does not indicate that the patient's clinical 
condition is such that other methods of transportation such as medical stretcher van, are contraindicated. The 
elements of the coverage criteria are not satisfied. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for ambulance services provided to the enrollee on December 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for angiography services (procedure code 75716) provided to the 
enrollee on October 18, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied code remains not supported. 
 
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 75716 is :Angiography, extremity, bilateral, radiological 
supervision and interpretation." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the operative report does not support 
CPT 75716 as a separate distinct procedure, as no documentation of previous diagnostic study was not 
available. Therefore, this service cannot be verified. 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for angiography services (procedure code 75716) provided to the enrollee on October 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder orthosis you provided on October 13, 2021. 
 
You asked the Plan to pay for the shoulder orthosis. You say that you have provided documentation to support 
payment. The Plan denied your request. The Plan says the documentation submitted does not support the order 
of this item. 
 
The Plan must follow Medicare rules. Medicare rules say that a treating practitioner have a face-to-face 
encounter with the patient within six months prior to prescribing items.  The face-to-face encounter must 
support payment for the item prescribed and be documented in the medical record.  In this case, we looked at 
the medical records from the ordering provider. While this provider did have a face-to-face encounter with the 
patient where shoulder pain was discussed, that encounter occurred on November 2, 2020. This is nearly a year 
prior to the shoulder brace being provided. More recent records from the treating practitioner do not reference 
shoulder pain in any way. Therefore, the face-to-face encounter where the records support the reason for 
ordering this item was performed outside of the required 6-month time frame. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the shoulder orthosis have not been met. Therefore, we decided that the Plan does not have to pay 
for the shoulder orthosis you provided on October 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional imaging services provided to the enrollee on 
October 14, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is no additional documentation supporting additional studies which were billed and remain 
denied. 
 
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 the denied codes is: 
 
CPT 77063: 
 
Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure) 
 
CPT 77067: 
 
Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) 
when performed 
 
We looked at the file and Medicare rules. A review of the file appears to show that the two imaging reports 
included are duplicates of each other. 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 additional 
imaging services provided to the enrollee on October 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 26, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
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 provided on August 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74176-26 billed for date of service December 
12, 2021. 
 You asked the Plan to pay for procedure code 74176-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 74176-26 is bundled into 
payment for code 74174-26. 
 
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 74176 
is a column II code to column I code 74174. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 74176-26 billed for date of service December 12, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (codes 82728 and 83540) billed for date of 
service September 10, 2021. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment of these services. The Plan denied your request. The Plan says payment for these lab services is 
bundled into the payment to the End Stage Renal Disease facility. The Plan says that because these lab services 
are the responsibility of the patient's dialysis facility, this claim should not have been submitted to the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that all end-stage renal disease (ESRD)-related 
laboratory services are included in the ESRD Prospective Payment System base rate and must be reported by 
the ESRD facility and are not separately paid.  These lab services were provided to an ESRD patient and are 
therefore not separately paid. 
 
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. Therefore, we decided that the Plan does not have to pay for lab 
services (codes 82728 and 83540) billed for date of service September 10, 2021.