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

 
We decided that the Plan does not have to waive the coinsurance for injection on February 16, 2022. 
 
You asked the Plan to waive the coinsurance for injection. You say that You want to know where the additional 
$0.24 has come from and would like it to be corrected and removed. The Plan denied your request. The Plan 
says the cost-sharing 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 a 20% 
coinsurance for all other Medicare-covered Part B drugs. For the administration of these drugs, you will pay the 
cost-sharing that applies to primary care provider services, specialist services, or outpatient hospital services 
(as described under Physician/ Practitioner Services, Including Doctors Office Visits or Outpatient Hospital 
Services in this benefit chart) depending on where you received drug administration or infusion services. 
These drugs are covered under Part B of Original Medicare. Members of our plan receive coverage for these 
drugs through our plan. Covered drugs include: Drugs that usually arent self-administered by the patient and 
are injected or infused while you are getting physician, hospital outpatient, or ambulatory surgical center 
services. The provider billed in the amount of $12 and the allowed amount is $1.20. The plan paid $0.96.  
$1.20 x 20% = $0.24 Therefore, results in the total cost-sharing amount of $0.24.  
You have been asked to pay a 20% coinsurance for injection. Injections 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 injection on 
February 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda, Pemetrexed, Carboplatin, Famotidine, and 
Diphenhydramine. 
 
You asked the Plan to pre-approve Keytruda, Pemetrexed, Carboplatin, Famotidine, and Diphenhydramine. 
You say that the services are necessary. The Plan denied your request. The Plan says based on the 
documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Keytruda, Pemetrexed, Carboplatin, 
Famotidine, and Diphenhydramine. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found the Food and Drug Administration has not stated that the requested drug is indicated 
for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation 
for the use of the requested drug in the enrollee's clinical situation. No literature from Medicare approved 
cancer journals were submitted for review. The elements of the coverage criteria are not satisfied. The 
requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda, Pemetrexed, Carboplatin, Famotidine, and Diphenhydramine have 
not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda, Pemetrexed, 
Carboplatin, Famotidine, and Diphenhydramine.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesia services (00142) provided on October 28, 2020. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the claim is a duplicate to another claim 
submitted that was already paid for. 
 
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 failed to provide supporting evidence to show the claim was previously 
submitted and paid for. In order to determine if a claim is a duplicate to another claim, both claims need to be 
reviewed per Medicare guidelines. Therefore, we decided that the Plan has to pay for the anesthesia services 
(00142) provided on October 28, 2020.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 8, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined 
these services can be received in-network. 
 
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 laboratory services provided on March 8, 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 definitive drug testing rendered on September 16, 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 procedure code G0483 is 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 G0483 is definitive drug testing, 22 or more drug classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the file shows that only 18 
drug classes were tested. 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 definitive drug 
testing rendered on September 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oncology (prostate) gene expression profile by real-time 
RT-PCR of 3 genes, described as ExoDx Prostate Intelliscore (EPI). You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the Prostate Specific Antigen (PSA) level is greater than 10 ng/dl. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee does not meet the criteria for the testing. The enrollee has an elevated PSA of 26.9 
ng/ml, which is over the covered range for this testing. 
 
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 pre-approve oncology (prostate) gene expression profile by real-time RT-PCR of 3 genes, described as 
ExoDx Prostate Intelliscore (EPI).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a supply allowance (K0553) and receiver for therapeutic 
continuous glucose monitor (CGM) (K0554). 
 
You asked the Plan to pre-approve a supply allowance and receiver for therapeutic CGM. The Plan denied your 
request. The Plan says the enrollee does not need insulin 3 times a day, and does not need to adjust their insulin 
frequently. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a supply allowance (K0553) and 
receiver for therapeutic continuous glucose monitor (CGM) (K0554). have been met. Medical records were not 
provided for this case. The Plan requested medical records, but they were not received. Without this 
information we cannot determine that this request is medically necessary and meets the criteria for coverage. 
Therefore, we decided that the Plan does not have to pre-approve a supply allowance (K0553) and receiver for 
therapeutic continuous glucose monitor (CGM) (K0554).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and coinsurance for a portable oxygen 
concentrator provided by an out-of-network (OON) provider from January 12, 2022, to March 12, 2022. 
 
You asked the Plan to waive the deductible and coinsurance for the OON oxygen concentrator. You say that 
you were unaware the provider was out-of-network. The Plan denied your request. The Plan says the correct 
deductible and coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $500 out-of-network deductible which applies to certain items and 
services. 
 
Your contract with the Plan also clearly says that you must pay an 8% coinsurance for each durable medical 
equipment (DME) item, including oxygen equipment, from an out-of-network (OON) provider. 
 
 Item Allowed Amount Deductible/Coinsurance 
Portable Oxygen Machine  January 12, 2022 $151.15 $151.15 (D) 
Oxygen Concentrator  January 12, 2022 $48.39 $48.39 (D) 
Portable Oxygen Machine  February 12, 2022 $151.15 151.15 (D) 
Oxygen Concentrator  February 12, 2022 $48.39 $48.39 (D) 
Portable Oxygen Machine  March 12, 2022 $151.15 $100.92 (D)/$4.02 (C) 
Oxygen Concentrator  March 12, 2022 $48.39 $3.87 (C) 
Total:  $507.89 
 
The item or service you asked the Plan to waive the deductible and coinsurance for falls within Durable 
Medical Equipment (DME) and Related Supplies the benefit category. The Plan has followed Medicare rules 
by clearly disclosing in the contract that there is $500 out-of-network deductible which applies to certain items 
and services.  
 
Once the deductible was met on March 12, 2022, the 8% coinsurance was applied to the remainder of the 
allowed amount. For the portable oxygen machine, $100.92 was applied first to meet the $500 out-of-network 
deductible. The remaining allowed amount was $50.23, of which the 8% coinsurance was applied. The total for 
all deductible and coinsurance amounts is $507.89. This cost sharing is a contractual obligation that had not 
been met at the time the OON oxygen concentrator was provided from January 12, 2022, to March 12, 2022. 
Therefore, we decided that the Plan does not have to waive the deductible and coinsurance for a portable 
oxygen concentrator provided by an out-of-network (OON) provider from January 12, 2022, to March 12, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endovascular revascularization services (procedure code 
37232) provided to the enrollee on February 15, 2022. 
 
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 procedure code 37232-RT is not supported by the medical records submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 37232 is "open or percutaneous endovascular 
revascularization, of a unilateral tibial/peroneal artery, for each additional vessel, with transluminal angioplasty 
(listed separately in addition to code for primary procedure)." 
 
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 that the documentation does not 
support that CPT 37232 - open or percutaneous endovascular revascularization, of a unilateral tibial/peroneal 
artery, for each additional vessel, with transluminal angioplasty (listed separately in addition to code for primary procedure) - was rendered in this case. 
 
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 endovascular revascularization services (procedure code 37232) provided to the enrollee on 
February 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 12, 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 are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on January 12, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network diagnostic ultrasound 
provided on February 10, 2022. 
 
You asked the Plan to waive the copayment for an in-network diagnostic ultrasound. You say that you should 
only have a specialist copayment, not a diagnostic test copayment. 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 $150 
copayment for other outpatient diagnostic tests.   
 
You have been asked to pay the allowed amount of $92.29, which is less than the $150 copayment for an in-
network diagnostic ultrasound. An in-network diagnostic ultrasound falls within the Other Outpatient 
Diagnostic Tests -Radiological Diagnostic Services, Not Including X-Rays 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 in-network diagnostic ultrasound provided on February 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad and pump rendered on May 
26, 2021, to June 3, 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 the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a water circulating heat pad with pump is denied 
as not medically necessary. 
 
We looked at the file and Medicare rules. The item at issue is a water circulating heat pad with pump. This item 
is denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have to pay for 
the water circulating heat pad and pump rendered on May 26, 2021, to June 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a heart loop monitor for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is a lack of documented syncope. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has no history of atrial fibrillation, nor were any significant cardiac arrhythmias noted 
on monitoring. A recent randomized clinical trial found that continuous monitoring for atrial fibrillation with 
an implanted loop recorder (ILR) (followed by treatment with oral anticoagulation if atrial fibrillation was 
detected) was not superior to usual care in reducing stroke or systemic embolism among patients at high risk of 
stroke but without a known prior history of atrial fibrillation. At this time, insertion of an ILR would not be 
considered medically appropriate and necessary in this patients clinical management. 
 
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 pre-approve insertion of a heart loop monitor for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for laboratory services provided on February 
18, 2022, and February 24, 2022. 
 
You asked the Plan to waive the deductible for the lab services. You say that you were advised there would be 
no cost for the services. The Plan denied your request. The Plan says the correct amount was applied to your 
deductible. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $250 deductible which applies to certain items and services 
 
 
 
 
 
 
 
 
 
 The services you asked the Plan to waive the deductible for fall within the Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies benefit category. The Plan has followed Medicare rules by clearly disclosing 
in the contract that there is $250 deductible which applies to certain items and services. This cost sharing is a 
contractual obligation that had not been met at the time the lab services were received on February 18, 2022, 
and February 24, 2022. Therefore, we decided that the Plan does not have to waive the deductible for 
laboratory services provided on February 18, 2022, and February 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 standard power wheelchair (K0835) with 
related supplies and accessories. 
 
You asked the Plan to pre-approve a Group 2 standard power wheelchair. You say that the requested item is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for power 
mobility devices have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 Group 2 standard power wheelchair. 
Our reviewer says that the requested item is not medically reasonable and necessary in this case.  
 Our physician reviewer found that there is insufficient clinical documentation indicating the enrollees 
functional level with regards to performing activities of daily living and the enrollee's need for a powered 
mobility device to perform mobility related activities of daily living. The enrollee is noted to have 4/5 motor 
strength in the upper extremities, and it is not clear why the enrollee cannot propel an optimally configured 
manual wheelchair. 
 
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 Group 2 standard power wheelchair have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Group 2 standard power wheelchair (K0835) with related supplies 
and accessories.