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

 
We decided that the Plan does not have to waive the coinsurance for injections provided on January 4, 2022. 
 
You asked the Plan to waive the coinsurance for injections. You say that you should only have to pay $50 
copayment. The Plan denied your request. The Plan says the coinsurance applied 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 20% 
coinsurance for each Medicare-covered Part B drug and non-chemotherapy drugs to treat cancer.  
 
You have been asked to pay a total of $1,249.87 which is 20% of the allowed amount for the injections. The 
allowed amount is $6,249.43 (20% x $6,249.43=$1,249.87). 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 injections provided 
on January 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing (G0481) provided on November 8, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the medical records provided support the 
necessity of the services in dispute 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the definitive drug testing (G0481) provided on 
November 8, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the additional trips are 
needed because you have dialysis appointments three times a week and you have dementia. The Plan denied 
your request. The Plan says additional trips would exceed your benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 trips per year.  
 
 We looked at your request, the records in the case file, and the rules. The records show that you have used 
fifty-eight (58) one-way transportation trips out of the allowed sixty (60) one-way trips approved. Once 60 trips 
are used, the benefit will be exhausted. Based on this information, we decided that the Plans rules for coverage 
of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve 
additional routine transportation trips (A0120).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 25, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. 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 genetic testing provided on June 25, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the SNF stay provided from September 7, 2021, to 
September 19, 2021. 
 
  You asked the Plan to pay for the SNF stay. You say that hospice services were terminated on September 3, 
2021, once the enrollee was admitted into the hospital. The Plan denied your request. The Plan says original 
Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a skilled nursing facility (SNF) stay provided from September 
7, 2021, to September 19, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the continuous glucose monitor (CGM) supplies rendered on December 
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 that the information needed to consider the charge is not documented. 
 
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 states that the documentation lacks the information needed to consider 
the charge; however, the Plan has not provided a clear denial reason or listed what documentation is not present 
for the services to be covered. The Plan has not provided any Medicare rules to support that the services are not 
covered. Therefore, we decided that the Plan has to pay for the continuous glucose monitor (CGM) supplies 
rendered on December 27, 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve use of Durysta. 
 
You asked the Plan to pre-approve Durysta. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that the denial of authorization for this drug is correct, because Durysta is 
contraindicated due to the enrollee's Fuchs' dystrophy. 
 
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 Durysta. Our reviewer says that the 
enrollee meets the Medicare criteria for the requested use of Durysta. Our physician reviewer found Durysta 
received Food & Drug Administration (FDA) approval in March 2020 to reduce intraocular pressure in patients 
with open angle glaucoma. The documentation supports that the requested drug is safe and effective and 
otherwise medically reasonable and 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 Durysta have been met. Therefore, we decided that the Plan has to pre-approve 
use of Durysta.  
 
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 lab services (G0483) provided February 9, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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 Drug Testing, 22 or more drug classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not show 
testing for 22 or more drug classes. Based on this information, we decided that Medicare rules for coverage of 
the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services 
(G0483) provided February 9, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received from November 6, 2021, to 
November 11, 2021. 
 
You asked the Plan to pay for the drugs. You say that this should be paid for. The Plan denied your request. 
The Plan says this is not a covered benefit. 
 
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 pay for self-administered drugs received 
from November 6, 2021, to November 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for methadone treatment services (G2067, G2078) provided on 
January 5, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for methadone treatment services. You say that the requested services were a 
necessity for the enrollee's care. The Plan denied your request. The Plan says rules for payment for out-of-
network services 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 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 methadone treatment services (G2067, G2078) 
provided on January 5, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (77080) provided October 7, 2021. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim was not billed with a valid diagnosis code. 
 
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 77080 is not supported in the medical record. Specifically, Z13.820 (Encounter for 
screening) was the only diagnosis code listed. Based on this information, we decided that Medicare rules for 
coverage of the radiology services have not been met. Therefore, we decided that the Plan does not have to pay 
for radiology services (77080) provided October 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from July 
1, 2020 to July 31, 2020. 
 
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 the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a final corrected claim for the services was not filed until October 13, 2021. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from July 1, 
2020 to July 31, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computerized tomography (CT) scan provided on January 
26, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a computerized tomography (CT) scan. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network 
and authorization is required prior to an out-of-network visit. 
 
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 a computerized tomography (CT) scan provided 
on January 26, 2022 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hip orthosis (L1686) and related supply (L2624) provided 
on February 3, 2022. 
 
You asked the Plan to pay for a hip orthosis and related supply. You say that the items at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have 
not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in 
the patients medical record adequately supports the medical necessity for the item.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The available medical records do not discuss the items at issue. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for a hip orthosis (L1686) and related supply (L2624) provided on February 3, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 74018-26 billed for date of service July 28, 2021. 
 
You asked the Plan to pay for procedure code 74018. You say that this code should not be bundled. The Plan 
denied your request. The Plan says that payment for code 74018-26 is bundled into payment for code 74420. 
 
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 74420. That being said, the provider who billed code 74420 is not the 
same provider that billed code 74018-26.  There is no evidence that the two providers are related or share a 
National Provider Identifier (NPI).  The Plan has made no argument beyond the simple column I/Column II 
bundling argument.  This argument is not supported if the providers of the two codes are not the same.  The 
Plan has failed to provide any other support for its denial of this code. Therefore, we decided that the Plan has 
to pay for procedure code 74018-26 billed for date of service July 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically reasonable 
and necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure 
is considered experimental/investigational. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is a 66-year-old female being treated for other intervertebral disc 
degeneration of the lumbosacral region. She presented with low back and neck pain. She wishes to move 
forward with the L5-S1 Intracept. She notes the low back pain is constant but can flare up and get worse. She 
feels stiff and achy and unstable at times. Associated symptoms include numbness and tingling in the lower 
bilateral lower extremities and feet, associated with peripheral neuropathy. Aggravating factors include 
bending, exercise, getting out of bed, household chores, sitting, transitioning from sitting to standing, walking, 
and yard work. The exam reveals tenderness to the lumbar spine and lumbar facet columns. The range of 
motion is within normal limits. Strength and sensation are intact. However, non-radiating midline back pain, the noted pain-aggravating and pain-relieving factors, and intact 
neurologic exam were/are all non-specific to any pathologic entities. In this case, there were/are multiple 
plausible pathologic sources of significant pain generation. Overall, documentation was/is lacking regarding 
reasonably detailed and/or evidenced findings supportive of the spinal vertebral bodies as being the 
overwhelming primary generators of the enrollees chronic persistent pain. Documentation does not support 
actual formal surgical ablation of pre-designated basivertebral nerves as being medically necessary and/or 
reasonable at this time. Overall, there is no compelling rationale presented or extenuating circumstances noted 
to support the medical necessity of this request as an exception to guidelines. Therefore, the request for 
Intracept intraosseous nerve ablation at L5-S1 is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 testing (87426) provided August 8, 2021. 
 
You asked the Plan to pay for the COVID-19 testing. You say that this service should be covered. The Plan 
denied your request. The Plan says this test was for travel purposes and is non-covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the COVID-19 testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for COVID-19 testing (87426) provided August 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a seat lift purchased on January 7, 2022. 
 
You asked the Plan to pay for a seat lift. You say that this was not available from a medical supplier. The Plan 
denied your request. The Plan says this cannot be reimbursed. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a seat lift purchased on January 7, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge services and an office exam provided 
on October 11, 2021, and October 12, 2021. 
 
You asked the Plan to pay for hospital discharge services and an office exam. You say that you would like 
these services paid. The Plan denied your request. The Plan says original Medicare is responsible for payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospital discharge services and an office exam provided on 
October 11, 2021, and October 12, 2021.