Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for ophthalmic diagnostic imaging provided on 
March 22, 2022. 
 
You asked the Plan to waive the deductible for the ophthalmic imaging. You say that the enrollee was not 
aware of the deductible. The Plan denied your request. The Plan says the correct amount was applied to the 
enrollee's 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 ophthalmic imaging falls 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 ophthalmic imaging was received on March 22, 2022. Therefore, we decided that the 
Plan does not have to waive the deductible for ophthalmic diagnostic imaging provided on March 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower leg prosthetic items. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee's current foot is not 
appropriate for the enrollee's weight. The Plan denied your request. The Plan says the request exceeds the 
enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that lower limb prosthetics are only covered under certain 
medical indications.  
 
The file shows that a below knee alignable system (L5910) was requested. The records show that this item was 
approved in April 2022. There is no indication that the approved system needs to be replaced.  
 
The file also shows that a level 2 foot system was requested. 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 the enrollee can walk about a 
mile, but he does this in the home when his wife is present. The record indicates the enrollee is a home 
ambulator. There is no evidence he is a limited community ambulator. The record does not support a request 
for a level 2 system. 
 
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 lower leg prosthetic items.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Rituxan. 
 
You asked the Plan to pre-approve Rituxan. You say that the enrollee already received the first dose. The Plan 
denied your request. The Plan says that the drug is not covered for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Rituxan. Our physician reviewer found 
that the enrollee has biopsy proven antineutrophilic cytoplasmic antibody (ANCA) vasculitis that has been 
treated with Rituximab in past. Has recurrence of vasculitis and provider wishes to start maintenance 
Rituximab. This has been denied due to the fact that it is approved with steroids and not alone. Rituximab is 
indicated, but with steroids. This is typically with induction therapy. There is literature and common practice to 
support the use of maintenance Rituximab without steroids. The documentation supports the use of Rituximab 
in this fashion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Rituxan have been met. Therefore, we decided that the Plan has to pre-approve 
Rituxan.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the venography (75820) and injection procedure for 
extremity venography (36005) provided on November 24, 2021. 
 
You asked the Plan to pay for the venography (75820) and injection procedure for extremity venography 
(36005). You say that the claim should be reviewed and reprocessed for payment. The Plan denied your 
request. The Plan says procedure codes 36005 and 75820 are considered inclusive to procedure code 37238. 
 
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 75820 is a column II code to column I code 37238; however, 75820 
was billed with a modifier.  
 
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 venography (75820). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that a 
diagnostic venography can be coded separately with a venous stent placement only when the venography is 
truly diagnostic. The operative report does not support the venography was a diagnostic procedure.  
 
In addition, we have confirmed that code 36005 is a column II code to column I code 37238. This code has not 
been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. 
 
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 venography (75820) and injection procedure for extremity venography 
(36005) have not been met. Therefore, we decided that the Plan does not have to pay for the venography 
(75820) and injection procedure for extremity venography (36005) provided on November 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on November 23, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the diagnosis code was not billed with the highest 
specificity. 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 drug testing rendered on November 
23, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has met the criteria for an 
injection at L5 and S1. The Plan denied your request. The Plan says that there is no documentation of a plan to 
treat a second level. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are only covered under 
certain medical indications.  
 
The file shows that 2 levels of injections. The Plan has agreed to pre-approve 1 level. 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 you 
have chronic low back with radiation. You are status post anterior fusion at L5-S1. You are taking over the 
counter medications and Gabapentin. The request is for 2 levels of transforaminal epidural steroid injections. 
You have had surgery that spans the L5 and S1 vertebral bodies. The request for 2 levels meets the coverage 
criteria and is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have been met. Therefore, we decided that the Plan has to 
pre-approve epidural steroid injections.  
 
 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have waive the $50 copayment for an emergency room visit on March 27, 
2022. 
 
You asked the Plan waive the $50 copayment for an emergency room visit. You say that you should not be 
responsible for this copayment. The Plan denied your request. The Plan says the copayment has been applied 
correctly. 
 
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 an emergency room visit.  
 
You have been asked to pay $50 for an emergency room visit. An emergency room visit falls within the 
Emergency Care benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have waive the $50 copayment for an emergency 
room visit on March 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept intraosseous ablation of the basivertebral 
nerve. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has tried and failed 
conservative treatment. The Plan denied your request. The Plan says this service is considered experimental. 
 
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 the Intracept procedure targets the basivertebral nerve for the relief of chronic 
vertebrogenic low back pain. Medicare guidelines consider this type of system unproven and not medically 
necessary. Large well-designed studies in the peer review scientific literature comparing stand-alone use of 
Intracept device to established surgical decompression are needed. Published studies do not demonstrate any 
long-term health outcome advantage with the use of Intracept as an alternative to standard surgical treatment. 
The review has determined that the requested Intracept procedure is not medically reasonable or necessary for 
the enrollee. 
 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 an Intracept intraosseous ablation of the basivertebral nerve.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the targeted genomic sequence analysis, solid organ neoplasm, DNA 
analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, gene 
rearrangements, microsatellite instability and tumor mutational burden (0037U) provided February 10, 2022. 
 
You asked the Plan to pay for the FoundationOne CDx (F1CDx) test. You say that this test is a medically 
necessary covered benefit. The Plan denied your request. The Plan says that the next generation sequence 
testing (NGS) testing panel performed included testing for FANCC genes. Testing for these genes is not a 
Medicare benefit and is statutorily excluded service. 
 
The Plan must follow Medicare rules. Medicare rules say that the FoundationOne CDx test is covered when it 
is FDA approved for the enrollees diagnosis. 
 
We looked at the file and Medicare rules. In this case the documentation shows that the F1CDx test was 
performed for the enrollees diagnosis of non-small cell lung cancer. Non-small cell lung cancer is a covered 
indication for F1CDx. Based on this information, we decided that Medicare rules for coverage of the 
FoundationOne CDx (F1CDx) test have been met. Therefore, we decided that the Plan has to pay for the 
targeted genomic sequence analysis, solid organ neoplasm, DNA analysis of 324 genes, interrogation for 
sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability and tumor 
mutational burden (0037U) provided February 10, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation provided to the enrollee on 
October 13, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the medical documentation provided indicates that the response to the scene was 
classified as non-emergent. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found that the 
enrollee had a head injury with large scalp hematoma, and leg and hip pain after a fall at the nursing home. The 
enrollee's presenting symptoms met prudent layperson criteria for emergency care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for ambulance transportation provided to the enrollee on October 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has very limited capacity to participate and participate in therapy. The 
enrollee's chronic medical condition prohibits him from participating and benefiting from intensive therapy. 
There are no complex needs, and frequent physiatry oversight is not 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $243.34 copayment for outpatient surgery performed on 
March 22, 2022. 
 
You asked the Plan to waive the $243.34 copayment for outpatient surgery. You say that in the past the 
copayment for this procedure was lower. The Plan denied your request. The Plan says the copayment was 
applied correctly. 
 
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 $390 
copayment for surgery.  
 
You have been asked to pay $243.34 for outpatient surgery which is less than your $390 copayment. Outpatient 
surgery falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the $243.34 copayment for 
outpatient surgery performed on March 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for manual therapy and electrical stimulation provided by a 
chiropractor on August 26, 2021. 
 
You asked the Plan to pay for manual therapy and electrical stimulation. You say that you never received 
payment for these services. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because these services are not covered by Medicare or the Plan when performed by a 
chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for manual therapy and electrical stimulation provided by a chiropractor on 
August 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have waive the copayment for outpatient mental health services provided 
January 19, 2022, to May 22, 2022.  
 
You asked the Plan waive the copayment for outpatient mental health services. You say that you believed the 
provider was an in-network provider. The Plan denied your request. The Plan says the cost share has been 
applied correctly. 
 
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 Outpatient Mental Health Care.  
 
You have been asked to pay $495.42 for outpatient mental health services. Outpatient mental health services 
fall within the Outpatient Mental Health Care benefit category. Please note that for services rendered April 8, 
2022, to April 27, 2022 you were asked to pay a $30 copayment per date of service, which is less than the 40% 
coinsurance amount. 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 waive the copayment for outpatient mental health services 
provided January 19, 2022, to May 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74018 billed for date of service March 27, 
2022. 
 
You asked the Plan to pay for procedure code 74018. You say that you have provided medical records to 
support the service billed. The Plan denied your request. The Plan says payment for code 74018 is bundled into 
payment for code 74270. 
 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 74018 
is a column II code to column I code 74270. 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 74018 billed for date of service March 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dialysis services to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the dialysis service. You say that you would like to maintain your dialysis 
treatment with this provider. The Plan denied your request. The Plan says they have a contracted dialysis 
facility that it available for a coordinated care transition to provide the same service at a less distance, same 
time shift and with your current nephrologist. 
 
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 dialysis services to be provided by an out-of-network provider.