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

 
We decided that the Plan does not have to waive the coinsurance for chemical agents used for a cardiovascular 
stress test provided on May 20, 2021. We also decided that the Plan does not have to waive the coinsurance for 
a regadenoson injection and saline infusion provided on May 20, 2021. 
 
You asked the Plan to waive the coinsurance for the chemical agents and injection with saline infusion. You 
say that you were not aware of any cost sharing. The Plan denied your request. The Plan says the correct 
coinsurance was applied. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 10% 
coinsurance for medical supplies, including chemical agents used for diagnostic tests. 
 
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for Part B drugs. 
 
Drug/Supply Allowed Amount Coinsurance 
TC-99M (A9500) $121.70 $12.17 (10%) 
Thallous Chloride (A9505) $173.75 $17.38 (10%) 
Saline Infusion (J7050) $0.70 $0.14 (20%) 
Regadenoson (J2785) $237.25 $47.45 (20%) 
Total:  $77.14 
 
You have been asked to pay $77.14, which is the correct coinsurance for the chemical agents and injection with 
saline infusion. The chemical agents fall within the Outpatient Diagnostic Tests and Therapeutic Services and 
Supplies benefit category. The injection and saline infusion fall within the Medicare Part B Prescription Drugs 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the coinsurance for chemical agents used for a 
cardiovascular stress test provided on May 20, 2021. We also decided that the Plan does not have to waive the 
coinsurance for a regadenoson injection and saline infusion provided on May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus-diphtheria-acellular pertussis (Tdap) vaccine 
provided on November 19, 2021. 
 
You asked the Plan to pay for the Tdap vaccine. You say that this should be covered because it was required in 
order to accepted into an assisted living facility. The Plan denied your request. The Plan says this vaccine is not 
covered by Medicare Part B for preventive purposes. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Tdap vaccine. 
Therefore, we decided that the Plan does not have to pay for the tetanus-diphtheria-acellular pertussis (Tdap) 
vaccine provided on November 19, 2021.  
 
Benefits for the Tdap vaccine 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on June 14, 2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that the correct POS code was used for this 
service. The Plan denied your request. The Plan says the POS code reported does not match the location in 
which the sample was collected. 
 
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 Guardant360 testing 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 Guardant360 testing provided on June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Part B Drugs on July 15, 2021. 
 
You asked the Plan to waive the coinsurance for Part B Drugs. You say that you were advised by the provider 
that there wouldn't be additional fees. The Plan denied your request. The Plan says the 20% coinsurance 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 Part B Drugs. The total allowed amount of the Part B Drugs service is $3,640, resulting in a 
coinsurance amount of $728.  
 
You have been asked to pay 20% coinsurance for Part B Drugs. Part B Drugs fall within the Medicare Part B 
prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for Part B Drugs on 
July 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Jakafi. 
 
You asked the Plan to pre-approve Jakafi. You say that Jakafi is medically necessary. The Plan denied your 
request. The Plan says this is a self-administered drug that is not covered by the Plan. 
 
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 Jakafi.  
 
Benefits for Jakafi 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 pre-approve a cardiologist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a cardiologist office visit. You say that the out-of-network provider is the 
only one that can provide the surgery you need. The Plan denied your request. The Plan says the out-of-
network provider is not a registered provider and there are multiple in-network providers that provide the same 
quality of service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a cardiologist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of the ultrasound of the abdomen provided 
on December 3, 2021, billed with code 76705. 
 You asked the Plan to pay for the ultrasound interpretation. You say that this should be paid since multiple 
exams were done on the same date. The Plan denied your request. The Plan says this was not billed with an 
NCCI modifier as required. 
 
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 76705 
is a column II code to column I code 93976. 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 the interpretation of the ultrasound of the abdomen provided on 
December 3, 2021, billed with code 76705.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 CDx testing provided on July 21, 2021. 
 
You asked the Plan to pay for the Guardant360 CDx testing. You say that POS code 81 is correct for this 
service. The Plan denied your request. The Plan says the POS code on the claim is not supported. 
 
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 Guardant360 CDx testing 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 Guardant360 CDx testing provided on July 21, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing provided by an out-of-network provider on September 9, 
2021. 
 
You asked the Plan to pay for the drug testing. You say that the service was medically necessary. The Plan 
denied your request. The Plan says that no prior authorization was obtained. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
The enrollee was referred for the drug testing by a contract provider. The file does not show that the Plan 
provided notice that the drug testing would not be covered. Under Medicare rules, this means the drug testing is 
considered approved by the Plan. Therefore, we decided that the Plan has to pay for drug testing provided by an 
out-of-network provider on September 9, 2021. 
  
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgery provided on August 
9, 2021. 
 
You asked the Plan to waive the copayment for the outpatient surgery. You say that you go to see your primary 
care doctors at the same facility and that they do not charge a facility fee. The Plan denied your request. The 
Plan says the correct copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $395 
copayment for each Medicare-covered outpatient hospital visit or hospital outpatient surgical facility after you 
meet your $395 deductible.  
 You have been asked to pay a $204.66 copayment for the outpatient services, which is less than the $395 
copayment. The outpatient surgery falls within the Outpatient surgery, including services provided at hospital 
outpatient facilities and ambulatory surgical centers. 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 outpatient surgery provided on August 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of the computed tomography (CT) scan of 
the head provided on November 16, 2021, billed with code 70450. 
 
You asked the Plan to pay for the CT interpretation. You say that this should be paid. The Plan denied your 
request. The Plan says an NCCI modifier was not reported as required.  
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 70450 
is a column II code to column I code 70496. 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 the interpretation of the computed tomography (CT) scan of the 
head provided on November 16, 2021, billed with code 70450.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Shingrix vaccine provided on October 1, 2021. 
 
You asked the Plan to pay for the Shingrix vaccine. You say that you are 86 years old and consider this vaccine 
to be reasonable and necessary. The Plan denied your request. The Plan says this was correctly denied as only 
covered by Medicare Part D. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingrix 
vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Shingrix 
vaccine. Therefore, we decided that the Plan does not have to pay for the Shingrix vaccine provided on October 
1, 2021.  
 
Benefits for the Shingrix vaccine 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a microprocessor ankle foot system (L5973) with an 
alignable system (L5910). 
 
You asked the Plan to pre-approve a microprocessor ankle foot system with an alignable system. You say that 
these items are medically necessary. The Plan denied your request. The Plan says the records do not show why 
the requested computerized foot is needed. 
 
The Plan follows Medicare rules. The rules state that coverage for a foot prosthetic is extended only if there is 
sufficient clinical documentation of functional need for the technologic or design feature of a given type of 
foot. This information must be retained in the treating practitioner's or prosthetist's files. 
 
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 a microprocessor ankle foot system 
with an alignable system. Our reviewer says that the requested prosthetics are not medically necessary. Our 
physician reviewer found there is no evidence of a physiologic change requiring a new prosthetic foot. The 
documentation does not reveal irreparable change or damage to the foot or that repairs for the foot are needed. 
There is no evidence that your current prosthetic is damaged and requires replacement. The request for the 
microprocessor ankle foot system and alignable system exceed your medical need. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a microprocessor ankle foot system with an alignable system have not been met. Therefore, we decided that the Plan does not have to pre-approve a microprocessor ankle foot system (L5973) 
with an alignable system (L5910).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a specialist office visit. You say that you would like to continue to see the 
out-of-network provider. The Plan denied your request. The Plan says a list of in-network providers was given 
to the enrollee that provide the same quality of service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a chiropractor office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a chiropractor office visit. You say that you would like to see the out-of-
network provider because you have seen them before. The Plan denied your request. The Plan says there are in-
network providers that provide the same quality of service as an out-of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a chiropractor office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neurology visits to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the neurology visits. You say that the out-of-network provider is the only 
one that can provide the medical care that is needed. The Plan denied your request. The Plan says they have 
already approved the enrollee to see in-network providers that provide the same quality of 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
neurology visits to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of the computed tomography (CT) scan of 
the head provided on November 8, 2021, billed with code 70450. 
 
You asked the Plan to pay for the CT interpretation. You say that this should be paid. The Plan denied your 
request. The Plan says this was not billed with a required NCCI modifier.  
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 70450 
is a column II code to column I code 70496. 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 the interpretation of the computed tomography (CT) scan of the 
head provided on November 8, 2021, billed with code 70450.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a specialist office visit. You say that you would like to see the out-of-
network provide because the in-network provider retired. The Plan denied your request. The Plan says multiple 
in-network providers are available that provide the same quality of service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pradaxa. 
 
You asked the Plan to pre-approve Pradaxa. The Plan denied your request. The Plan says this drug is not 
covered under the Part B Plan. 
 
  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 Pradaxa.  
 
Benefits for Pradaxa may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.