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

 
We decided that the Plan does not have to pre-approve non-emergency ambulance services (A0428, A0425). 
 
You asked the Plan to pre-approve non-emergency ambulance services. You say that the requested service is 
medically necessary. The Plan denied your request. The Plan says the service at issue is not medically 
necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. 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 pre-approve non-emergency ambulance services. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the documentation 
does not support that other means of transport (such as stretcher van) are contraindicated. The documentation 
does not support that you need the expertise, services and lifesaving and life-sustaining equipment that only a 
fully-equipped ambulance can provide for safe transport. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of non-emergency ambulance services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve non-emergency ambulance services (A0428, A0425).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nexletol. 
 
You asked the Plan to pre-approve Nexletol. You say that the enrollee has multiple cardiovascular risk factors. 
The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition under 
Medicare 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 Nexletol.  
 
 Benefits for Nexletol 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 pay for the physician and imaging services provided on November 
23, 2021. 
 
You asked the Plan to pay for the physician and imaging services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the enrollee was in a covered 
Part A SNF stay. As such, payment must be made by the SNF. 
 
The Plan must follow Medicare rules. Medicare rules say that for most Medicare-covered services rendered to a 
Part A SNF inpatient, payment must be made under arrangements by the SNF and cannot be paid directly by 
another payer. 
 In this case, the enrollee was a SNF inpatient on November 23, 2021. These services are not payable by the 
Plan as they must be reimbursed by the SNF in question. Therefore, we decided that the Plan does not have to 
pay for the physician and imaging services provided on November 23, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for structural allograft services provided to the enrollee on November 28, 
2021. 
 
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 that procedure code 20931 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 20931 is "Allograft, structural, for spine surgery only (List 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 supported by the medical records. Our reviewer found the records do support that CPT 20931 - 
allograft, structural, for spine surgery only - was rendered in this case. The operative narrative clearly states 
that Allograft spacers were inserted into the bilateral C1-2 facet joint to facilitate C1-2 arthrodesis. 
(Allografts are noted to be prepared outside of the operating room and therefore, documentation that the 
allograft that has been prepared in a bicortical or tricortical shape for structural use would not be included in 
the operative narrative.) 
 
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 been met. Therefore, we decided that the Plan has to pay for 
structural allograft services provided to the enrollee on November 28, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an epidural injection provided on November 15, 2021. 
 
You asked the Plan to pay for an epidural injection. The Plan denied your request. The Plan says the Health 
Plan has not received the required clinical records to support the medical necessity of the service for the date of 
service requested. The records provided are undated and unsigned. There is insufficient documentation of 
response to prior injections. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 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 an epidural injection provided on 
November 15, 2021 have been met. Therefore, we decided that the Plan does not have to pay for an epidural 
injection provided on November 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 27, 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. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on August 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the selective visceral angiography (75726-26-XS) and 
selective angiography of three additional vessels (75774-26-XS x3) provided on July 28, 2021. 
 You asked the Plan to pay for the selective angiography services as billed. You say that this claim is billed 
correctly, and all line items should be paid. The Plan denied your request. The Plan says the angiography being 
described is reimbursed through code 37242. 
 
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 codes 75726 and 75774 are column II codes to column I code 37242; 
however, 75726 and 75774 were 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 selective angiography services as billed. Our reviewer 
says that the records do not support separate payment of these codes. Our reviewer found although these 
procedures are documented in the procedure report, they are inclusive to CPT 37242 (which includes all 
radiological supervision and interpretation) and would not be reported separately. 
 
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 selective angiography services as billed have not been met. Therefore, we 
decided that the Plan does not have to pay for the selective visceral angiography (75726-26-XS) and selective 
angiography of three additional vessels (75774-26-XS x3) provided on July 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 11, 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. The rules say that genetic testing procedures submitted under CPT code 
81455 are denied as not medically necessary. 
 
We looked at the file and Medicare rules. The services are billed under code 81455. 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 laboratory services rendered on November 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections (62320) provided December 13, 2021. 
 
You asked the Plan to pay for the injections. You say that the service was medically necessary. The Plan denied 
your request. The Plan says insufficient documentation was provided to support the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 injections (62320) provided December 13, 2021. have been met. Specifically, only a procedure note was provided. No clinical records were provided 
to show that this procedure was medically necessary. Therefore, we decided that the Plan does not have to pay 
for injections (62320) provided December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit to be provided by an OON provider. You say that the services 
are necessary. 
 The Plan denied your request. The Plan says there are in-network providers that are able to provide these 
services. Therefore, coverage criteria have not been met. 
 
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 
an 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 a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. 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. 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 a CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in enrollee management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees 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 a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM). 
 
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 criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not treat with insulin three 
or more times per day or use an insulin pump. 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 
a Dexcom G6 continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Auryxia. 
 
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 self-administered drugs are not covered. 
 
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 Auryxia.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for multiple density inserts provided on October 25, 
2021. 
 
You asked the Plan to waive the coinsurance for multiple density inserts. You say that you have been getting 
the same item every year and you never had any member responsibility. The Plan denied your request. The 
Plan says that coinsurance 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). The Plan contract does not clearly disclose how much enrollees 
should expect to pay for multiple density inserts.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay 20% 
coinsurance for diabetic shoes and inserts. The Plan contract does not clearly say how much enrollees must pay 
for diabetic shoes and inserts. This means that the Plan did not follow Medicare rules for disclosure of cost 
sharing information. Therefore, we decided that the Plan has to waive the coinsurance for multiple density 
inserts provided on October 25, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an Echocardiogram provided on February 17, 2022. 
 
You asked the Plan to pay for an Echocardiogram. The Plan denied your request. The Plan says an 
authorization was not submitted prior to the service 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 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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an Echocardiogram provided on February 17, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transport provided on 
December 28, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that you left the hospital by 
the owned hospital ambulance for rehabilitation at another hospital. You say that any reduction of this bill 
would be greatly appreciated. The Plan denied your request. The Plan says you have been charged the correct 
copayment 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 $275 
copayment per one-way trip.  
 
  
 
 
You have been asked to pay $230.61, which is less than the standard $275 copayment for the ambulance 
transport. Ambulance service falls within Ambulance Services 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 ambulance transport provided on December 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the use of this device is contraindicated by the manufacturer and the Food and Drug 
Administration (FDA) for severe stenosis. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the device is experimental. More research is needed to show safety and efficacy. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (96372, 97016) provided September 3, 
2021. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says insufficient records were provided. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 physician services (96372, 97016) 
provided September 3, 2021. have been met. The record shows the plan made multiple requests for additional 
records and none were provided. Therefore, we decided that the Plan does not have to pay for physician 
services (96372, 97016) provided September 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the x-ray exam of the foot (73630) and the 
computed tomographic angiography of the abdominal arteries (75635) provided on July 29, 2021 and 
September 22, 2021. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services provided. 
 
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 Medicare-covered x-rays and a $250 copayment for Medicare-covered diagnostic radiology 
services.  
You have been asked to pay $207.92 (33.09 + $174.83). This includes the Plans allowed amount of $33.09 for 
the Medicare-covered x-ray provided, which is less than the applicable copayment for this service. 
Additionally, this includes the Plans allowed amount of $174.83 for the Medicare-covered diagnostic 
radiology service provided, which is less than the applicable copayment for this service. 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 the x-ray exam of the foot (73630) and the computed tomographic 
angiography of the abdominal arteries (75635) provided on July 29, 2021 and September 22, 2021.