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

 
We decided that the Plan does not have to waive the copayments for an emergency room visit, computed 
tomography (CT) scan, and magnetic resonance imaging (MRI) scan provided from November 3, 2021, to 
November 4, 2021. 
 
You asked the Plan to waive the copayments for emergency room visit and advanced imaging scans. You say 
that the provider could not find anything wrong with you. The Plan denied your request. The Plan says the 
copayment amounts you are being charged are correct. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $90 
copayment for emergency room visit and $250 copayment for each advanced imaging service. Therefore, your 
total copayment amount is $340. 
 
You have been asked to pay $90 copayment for emergency room visit and $250 copayment for CT and MRI. 
Emergency room visit and advanced imaging scans fall within the "Emergency Care" and "Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies" benefit categories. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayments for an emergency room visit, computed tomography (CT) scan, and magnetic 
resonance imaging (MRI) scan provided from November 3, 2021, to November 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve blepharoplasty services to be provided at an out-of-
network (OON) facility. 
 
You asked the Plan to pre-approve blepharoplasty services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services can be provided by a 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 facility in this case is not a network facility with the Plan. The Plan has network facilities 
available where providers can provide the 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 blepharoplasty services to be provided at an out-of-network (OON) facility.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on August 5, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the testing was billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing can only be considered for 
coverage when billed with code 81479.  
 
We looked at the file and Medicare rules. In this case, the Guardant360 testing was billed with multiple CPT 
codes. Per LCA A58192, Guardant360 testing must be billed with code 81479. 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 the Guardant360 testing provided on August 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lupron Depot for the enrollee. 
 
You asked the Plan to pre-approve Lupron Depot. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says that there is no rationale provided for use of the non-preferred product 
for safety or efficacy. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Lupron Depot. Our reviewer says that 
Lupron Depot is not medically reasonable and necessary. The record indicates that the enrollee has prostate 
cancer. The requested medication is a new start. The provided records do not indicate that the enrollee has tried 
and failed the Plan's preferred step one alternative, Eligard. The record does not indicate that the enrollee has a 
contraindication to or would have an adverse effect from the Plan's preferred step one alternative. Our 
physician reviewer found that the enrollee's condition does not meet step therapy criteria for Lupron Depot. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lupron Depot have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Lupron Depot for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Yondelis. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
Plan's required drug, a prior anthracycline-based regimen. The records do not show that the required drug 
would be contraindicated or less effective; therefore, Yondelis is 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 pre-approve Yondelis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that the medical records provided will show proof 
of medical necessity. The Plan denied your request. The Plan says enrollees must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered. 
 
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 
the outpatient office visit to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar fusion services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
documentation did not show evidence of spinal instability. 
 
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 requested services. Our physician 
reviewer found that there is no lumbar instability, fracture, or lesion. Lumbar fusion is not medically needed in 
this case of degenerative back pain. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve lumbar fusion services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of a lower extremity joint 
(73721). 
 
You asked the Plan to pre-approve an MRI. You say that this imaging is medically necessary, and the enrollee 
has had a recent x-ray. The Plan denied your request. The Plan says that although the records indicate that x-
rays were ordered, the results of these x-rays was not submitted for review. Without this information, it cannot 
be verified that this MRI is medically necessary according to Medicare regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 an MRI. Our reviewer says that the 
requested MRI is reasonable and necessary in this case. Our physician reviewer found that while the records 
show that a plain film of the left hip has been ordered and no report is in the records, there is concern in this 
enrollee due to a history of urosepsis. The results of the ordered x-ray are highly unlikely to have an impact on 
whether MRI of the left hip will be needed. If the x-rays were to be negative the indication for MRI would still 
be present, especially given the history of prostate cancer and the history of urosepsis in the past. The real 
concern here would be to rule out metastatic disease and septic joint in this enrollee due to their history, and an 
MRI would be the best procedure of choice despite the lack of a report from ordered plain x-rays. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of a lower extremity joint (73721).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-preferred brand for diabetic supplies. 
 
You asked the Plan to pre-approve a non-preferred brand. The Plan denied your request. The Plan says the 
brand requested in not on the list of products covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that test strips and monitors must be obtained from preferred vendors. 
 
 
 
 The requested supplies are not from a preferred brand. The Plan has preferred vendors available who can 
provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve 
non-preferred items. Therefore, we decided that the Plan does not have to pre-approve a non-preferred brand 
for diabetic supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the miscellaneous supply or accessory for use with an 
implanted ventricular assist device (Q0508) provided March 1, 2021 to December 1, 2021. 
 
You asked the Plan to pay for the miscellaneous supply or accessory. You say that this insurance meets the 
primary payer's processing requirements and the Plan is responsible for the primary allowable and payment. 
The Plan denied your request. The Plan says an explanation of benefits from the enrollee's primary insurance 
carrier is needed before this claim can be considered. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has another 
payer as the primary payer. As the secondary insurer, the Plan cannot be held responsible for the miscellaneous 
supply or accessory until the primary insurer has denied the claim for these services. Therefore, we decided that 
the Plan does not have to pay for the miscellaneous supply or accessory for use with an implanted ventricular 
assist device (Q0508) provided March 1, 2021 to December 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 7, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the genetic testing. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
genetic testing. We found no exception that would require the Plan to pay the genetic testing. The records 
provided for review do not show that the genetic testing for urgent or emergent. Therefore, we decided that the 
Plan does not have to pay for the genetic testing provided on January 7, 2022, by an out-of-network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says the requested device does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found a diagnosis of COPD is listed, 
although there are no pulmonary function tests to confirm and assess severity. There is no diagnosis of 
neuromuscular disease or thoracic restrictive disease. The AVAPS mode can be provided with bipap, but there 
is no evidence this has been tried at home. Medicare does not cover a home ventilator when used as bipap. 
 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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services billed with code S0207 for date of 
service November 22, 2021. 
 
You asked the Plan to pay for code S0207. You say that you have rebilled this service with code A0432-GY. 
The Plan denied your request. The Plan says this code is not valid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code S0207 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code S0207 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of code S0207 have not been met. Therefore, we decided that the Plan does not have to pay for 
ambulance services billed with code S0207 for date of service November 22, 2021.  
 
Your appeal letter referenced rebilling this service with code A0432.  It does not appear as though the Plan has 
processed a reconsideration request for this code at this time.  This decision is limited to coverage of code 
S0207.  For questions about code A0432, please contact the Plan directly.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient office visits (99205, 99215) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the office visits. You say that you thought this provider was a participating 
provider with the Plan and you would like to appeal the denial. The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 
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 the outpatient office visits (99205, 99215) to 
be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the arthroplasty performed on December 9, 
2021. 
 
You asked the Plan to waive the copayment for the arthroplasty performed on December 9, 2021. You say that 
you should not be responsible for this copayment because it is a covered service. The Plan denied your request. 
The Plan says you are responsible to pay a $275 copayment for in-network outpatient hospital visits. 
 
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 $275 
copayment for Outpatient Surgery, Including Services Provided At Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 
You have been asked to pay a $275 copayment for an arthroplasty. An arthroplasty 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 copayment for the arthroplasty performed on 
December 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 10, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service and the attached reports support the level of service. You say that the claim should be reconsidered 
for processing. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment 
for code 70496.  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 procedure code 70450 billed for date of service March 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 27096, 77003 and A4550 billed on July 14, 
2021. 
 
You asked the Plan to pay for procedure codes 27096, 77003 and A4550. The Plan denied your request. The 
Plan says procedure codes 99214, Q9967, J3301, and J0670 were overturned. The Plan also says procedure 
code 27096 has a value of 1 per day, procedure code 77003 was billed without a primary procedure code and 
procedure code A4550 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 27096 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 27096 have not been met. In addition, we have confirmed that code 77003 is an add-on code 
and has not been billed with an appropriate primary procedure code. CPT code A4550 has a status indicator of 
B is not separately payable. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 77003 and A4550 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 27096, 77003 and A4550 billed on July 14, 2021.