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

 
We decided that the Plan does not have to pay for the outpatient office services provided on January 13, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient office services. You say that you would like to appeal the denied 
service. The Plan denied your request. The Plan says the rendering provider is an OON 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 the outpatient office services provided on January 
13, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Butrans for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
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 Butrans for the enrollee.  
 
Benefits for this drug 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 waive the copayment for a specialist office visit provided on 
February 14, 2022. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you were never told 
there would be a copayment and you would like it to be waived. 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 $15 
copayment for each specialist visit for Medicare-covered benefits (Including Telehealth services).  
 
  You have been asked to pay a $15 copayment for the specialist office visit. The specialist office visit falls 
within the Physician/Practitioner Services, including Doctors Office Visits 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 specialist office visit provided on February 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve, 
including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (CPT 64628). 
 
You asked the Plan to pre-approve thermal destruction of intraosseous basivertebral nerve, including all 
imaging guidance; first 2 vertebral bodies, lumbar or sacral. You say that thermal destruction of intraosseous 
basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral is medically 
necessary. The Plan denied your request. The Plan says thermal destruction of intraosseous basivertebral nerve, 
including all imaging guidance; first 2 vertebral bodies, lumbar or sacral is 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 pre-approve thermal destruction of intraosseous 
basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral. Our reviewer 
says that thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 
vertebral bodies, lumbar or sacral is not considered medically reasonable and necessary. Our physician 
reviewer found this an experimental/ investigational procedure whose role in chronic low back pain is still 
being considered. Therefore, the request is deemed 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 thermal destruction of intraosseous basivertebral nerve, including all imaging 
guidance; first 2 vertebral bodies, lumbar or sacral have not been met. Therefore, we decided that the Plan does 
not have to pre-approve thermal destruction of intraosseous basivertebral nerve, including all imaging 
guidance; first 2 vertebral bodies, lumbar or sacral (CPT 64628).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest radiologic examination coded 71046 provided on 
August 30, 2021. 
 
You asked the Plan to pay for the chest radiologic examination. You say that you would like the plan to 
reconsider their denial The Plan denied your request. The Plan says the services are not payable as billed. 
 
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 71046 is radiologic examination, chest; 2 views. 
 
We find that CPT code 71046 is not supported in the medical record. Specifically, the documentation shows 
that the provider is billing the technical component (TC) modifier on this claim and the professional component 
(PC) modifier 26 on a related claim. A provider cannot submit separate claims splitting these component 
modifiers for the same date of service. This means this claim was billed incorrectly. Based on this information, 
we decided that Medicare rules for coverage of the chest radiologic examination have not been met. Therefore, 
we decided that the Plan does not have to pay for the chest radiologic examination coded 71046 provided on 
August 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CxBladder genetic testing services provided on 
January 19, 2022. 
 
You asked the Plan to pre-approve the CxBladder genetic testing services. You say that this testing was 
medically reasonable and necessary. The Plan denied your request. The Plan says this test is statutorily non-
covered by Medicare. 
 
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 CxBladder genetic testing services. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that CxBladder testing is not considered a screening test for urothelial 
cancer. Cystoscopy, ureteroscopy, possible biopsy and upper tract imaging will still be necessary regardless of the results of Cxbladder testing. Urinary biomarker tests such as CxBladder give significant false-negative 
results in patients with urothelial cancer and are subject to false-positive results in others. Accuracy is poor for 
low-stage and low-grade tumors. The criteria for coverage have not been met. 
 
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 CxBladder genetic testing services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the CxBladder genetic testing services provided on January 
19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 8, 2021. 
 
You asked the Plan to pay for laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed as required 
by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
laboratory services provided on December 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve infusion supplies for external drug infusion pump, per 
cassette or bag (list drugs separately) (A4222). 
 
You asked the Plan to pre-approve infusion supplies. You say that the medical records provided support the 
necessity of the requested services. The Plan denied your request. The Plan says the records do not indicate that 
the enrollee meets the criteria. 
 
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 infusion supplies. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has active ulcerative proctocolitis and meets medical necessity criteria 
for Remicade infusion. Remicade is typically administered in an infusion center where the separate costs of 
infusion supply consumables are covered by the global infusion charge. The medical necessity of home 
infusion for the enrollee, other than for her convenience, is not met based on provided records. Nor is it 
medically appropriate for an infusion center to balance-charge patients for individual infusion supplies separate 
from the global infusion charge. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of infusion supplies have not been met. Therefore, we decided that the Plan does 
not have to pre-approve infusion supplies for external drug infusion pump, per cassette or bag (list drugs 
separately) (A4222).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on February 22, 
2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you did not see the provider for 
the full 20-30 minutes. The Plan denied your request. The Plan says the copayment applied was 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 $50 
copayment for Specialist Visits.  
 
You have been asked to pay a $50 copayment for a specialist visit. A specialist visit falls within the 
Physician/Practitioner Services, Including Doctors Office Visit 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 specialist visit provided on February 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a folding wheeled walker (E0143) provided on July 8, 2021, 
by an online retailer that is not enrolled in the Medicare program. 
 
You asked the Plan to pay for a folding wheeled walker. You say that you were unable to locate an in-network 
supplier who could provide the item at issue timely. The Plan denied your request. The Plan says rules for 
payment have not been met because the provider at issue is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a folding wheeled walker (E0143) 
provided on July 8, 2021, by an online retailer that is not enrolled in the Medicare program.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance and deductible for the durable medical 
equipment (DME) provided on December 13, 2021, January 5, 2022, and February 24, 2022. 
 
You asked the Plan to waive the coinsurance and deductible for the DME. You say that you were unaware that 
the provider was out-of-network, and you would like the Plan to cover the services. The Plan denied your 
request. The Plan says the proper cost share was applied because the provider is an out-of-network provider. 
 
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% 
coinsurance for each Medicare-covered item after you pay a $1000 deductible when you get these services out-
of-network. For the date of service of December 13, 2021, the total amount charged was $120.60 with a 
coinsurance of $24.12 ($120.60 total amount allowed x 20% coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for each Medicare-covered 
durable medical equipment item after you pay your plan deductible of $750 deductible when you get these 
services out-of-network. Prior to the date of services of January 5, 2022, and February 24, 2022, the $750 
deductible was not met. The total amount charged for January 5, 2022, was $253.30 and the total amount 
charged for February 24, 2022, was $379.80. The combined total amount was $633.10 which applied to the 
deductible leaving the remaining balance of $116.90 ($750 deductible - $633.10 charged deductible).  
 
You have been asked to pay a $24.12 coinsurance and a $633.10 deductible for the DME. The DME falls 
within the Durable medical equipment (DME) 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 and deductible for the durable medical equipment (DME) provided on December 13, 
2021, January 5, 2022, and February 24, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on January 14, 2022, to March 7, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. You say that in 2021 your Plan covered this provider/service 
with a $40 copayment as patient responsibility. You also say that this was an out-of-network copayment. You 
also say that you did not receive a notice explaining the difference between 2021 and 2022 benefits. The Plan 
denied your request. The Plan says your plan excludes coverage for this out-of-network 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 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 psychotherapy provided on January 14, 2022, to 
March 7, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-Melanoma testing rendered on February 14, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that DecisionDx-Melanoma testing is covered when 
specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has unspecified malignant 
melanoma of the skin. The dermatopathology report dated January 25, 2022 documents an amelanotic 
superficial spreading melanoma with a depth of invasion of 0.7mm, Clark's level Early IV, absent ulceration, 
and a mitotic count of two dermal mitoses/one mm2. The documentation supports that the enrollee's melanoma 
would be staged T1a. The criteria for coverage are not met and the testing is therefore not reasonable or 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the DecisionDx-Melanoma testing rendered on February 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  acupuncture provided on March 15, 2022. 
 
You asked the Plan to pay for acupuncture. You say that you were told acupuncture would be covered under 
your new plan. The Plan denied your request. The Plan says records show the acupuncture services were 
related to right elbow pain and not the lower back. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, you received acupuncture for the elbow and not for 
chronic low back pain. Therefore, we decided that the Plan does not have to pay for  acupuncture provided on 
March 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an office visit on January 5, 2022. 
 
You asked the Plan to waive the coinsurance for an office visit on January 5, 2022. You say that you should not 
be responsible to pay this coinsurance. The Plan denied your request. The Plan says you must pay a 40% 
coinsurance for specialist services. 
 
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 40% 
coinsurance for out-of-network physician specialist services.  
 
You have been asked to pay a $50 cost share for an office visit. An office visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. The $50 cost share is less 
than your contracted amount 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 
office visit on January 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for skin substitute graft procedures 
performed on July 20, 2021, and August 17, 2021. 
 
You asked the Plan to reduce the copayments for the graft procedures. You say that at the times of service you 
were told your copayment would only be $30. 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 $350 
copayment for outpatient surgery in an outpatient hospital facility.  
 
You have been asked to pay a $350 copayment for each of the graft procedures, for a total of $700. The graft 
procedures fall 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 reduce the copayments for skin 
substitute graft procedures performed on July 20, 2021, and August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anticoagulation clinic services coded S9401 provided on 
January 11, 2022. 
 
You asked the Plan to pay for the anticoagulation clinic services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not 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. 
 
In this case, the CPT Code Manual definition of code S9401 is anticoagulation clinic, inclusive of all services 
except laboratory tests, per session. 
 
We find that CPT code S9401 is not supported in the medical record. Specifically, this code has a status code 
of "I". This means that this code is not valid for Medicare purposes. Medicare uses another code for reporting 
of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of 
the anticoagulation clinic services have not been met. Therefore, we decided that the Plan does not have to pay 
for the anticoagulation clinic services coded S9401 provided on January 11, 2022.