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

 
We decided that the Plan does not have to reduce the copayment for a duplex scan of extracranial arteries 
provided on January 19, 2022. 
 
You asked the Plan to reduce the copayment for a duplex scan of extracranial arteries. You say that you are 
being charged $100 for your ultrasound. You also say that you only pay $40 for a specialist even if they are 
out-of-network. The Plan denied your request. The Plan says you were charged the correct cost sharing 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 $100 
copayment for radiological diagnostic services, not including x-rays, performed in a physician's office or at a 
free-standing facility.  
 
You have been asked to pay a $100 copayment for a duplex scan of extracranial arteries. A duplex scan of 
extracranial arteries falls within the outpatient diagnostic tests and therapeutic services and supplies 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 reduce the copayment for a duplex scan of extracranial arteries provided 
on January 19, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for flexible colonoscopy (procedure code 45388) provided to the 
enrollee on April 22, 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 the procedure code 45388-PT 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 45388 is "Colonoscopy, flexible; with ablation of 
tumor(s), polyp(s), or other lesion(s) (includes pre-and post-dilation and guide wire passage, when performed)." 
 
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 that the record indicates that the enrollee 
underwent hot snare polypectomy. The described procedure has a different CPT code. The requested code is 
incorrectly billed. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for flexible colonoscopy (procedure code 45388) provided to the enrollee on April 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on February 2, 2022. 
 
You asked the Plan to pay for the psychotherapy. The Plan denied your request. The Plan says the claim does 
not meet criteria for approval because there are contracted providers in the area of residence that accept new 
patients. In this case the provider is non-contracted, and visit is not preauthorized as required by the Medicare 
Evidence of Coverage Point of Service benefit. 
 
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 psychotherapy provided on February 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endoscopic decompression of neural elements and/or 
excision of herniated intervertebral discs (CPT code 62380). 
 
You asked the Plan to pre-approve the outpatient surgery. You say that the service is necessary. The Plan 
denied your request. The Plan says the requested service 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 outpatient surgery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found endoscopic decompression of the spine is experimental and more research is needed 
 
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 outpatient surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve endoscopic decompression of neural elements and/or excision of herniated 
intervertebral discs (CPT code 62380).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve RFA, nerves innervating the SI joint, with image 
guidance (CPT code 64625). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the notes show that the enrollee's doctor wants to do this procedure at the 
sacroiliac joint. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows this 
request to be an effective and/or safe treatment for the noted pathology. Additionally, the x-rays of the bilateral 
pelvis reveal no significant abnormality in the pelvis or hips. Multiple other plausible pain generators including 
at the lumbosacral spine are evident. There is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception. Therefore, the requested RFA, nerves 
innervating the SI joint, with image guidance (CPT 64625), in this case, 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve RFA, nerves innervating the SI joint, with image guidance (CPT code 64625).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the diabetic shoes and inserts (CPT code A5512). 
 
You asked the Plan to pre-approve the diabetic shoes and inserts. You say that the services are necessary. The 
Plan denied your request. The Plan says that the diabetic shoes and inserts are medically necessary for your 
condition. The Plan states your care can be directed to another provider who has given these services to a lot of 
patients. 
 
The Plan must follow Medicare rules. The plans documentation states that the provider is in-network, and 
theres no provision in the evidence of coverage (EOC) about diabetic supplies needing specific preferred 
providers. Therefore, we decided that the Plan has to pre-approve the diabetic shoes and inserts (CPT code 
A5512).  
 
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 waive the copayment for X-rays of the chest provided on February 1, 
2022. 
 
You asked the Plan to waive the copayment for the X-rays. You say that the service was approved by the VA. 
The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $95 
copayment for basic radiological services at an outpatient hospital.  
 
You have been asked to pay $76.01, which is less than the $95 copayment for the X-rays. Please note that the 
Plan does not have jurisdiction over other entities. The correct billing responsibility remains with the provider. 
The X-rays fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 X-rays of the chest provided on February 1, 2022.
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 13, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. 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 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on October 
4, 2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that you should not have to pay 
because of bad service. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing 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 $35 
copayment for specialist services.  
 
 
 
 
 
 You have been asked to pay a $35 copayment for the office visit. The office visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits 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 a specialist office visit provided on October 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve peripheral angiogram, angioplasty, atherectomy and 
stent placement. 
 
You asked the Plan to pre-approve peripheral angiogram, angioplasty, atherectomy and stent placement. 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 follows Medicare rules. Medicare rules say that interventions for peripheral vascular disease are 
covered when specific criteria are met. 
 
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 peripheral angiogram, angioplasty, 
atherectomy and stent placement. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found the record does not document that the criteria for a standalone arteriogram or 
intervention have been established. The elements of the coverage criteria are not satisfied. The requested 
service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of peripheral angiogram, angioplasty, atherectomy and stent placement have not 
been met. Therefore, we decided that the Plan does not have to pre-approve peripheral angiogram, angioplasty, 
atherectomy and stent placement.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the UBIDou 3 communication device (CPT code 
E2508). 
 
You asked the Plan to pre-approve the device. You say that the modes the enrollee uses to communicate have 
not proven effective in their life. You state the enrollee will benefit from having a SGD to communicate with 
hearing people when an interpreter in not available 90% of the time in their everyday life. The Plan denied your 
request. The Plan says the enrollee does not have any experience with the use of this device (UBIDou 3) and 
has not trialed the device at home or the community. The Plan states it has not been proven that the enrollee s 
communication skills will be more effective because of this device. 
 
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 physician reviewer 
found Medicare rules say that in order for a SGD to be covered the enrollee's needs must not be able to be met 
using natural communications methods. The review has determined that the medical records provided meet the 
requirements listed in the LCD for Medicare coverage. 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 UBIDou 3 communication 
device (CPT code E2508).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) test (0037U) provided April 
21, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that the provision of F1CDx to the enrollee meets 
the requirements of the NCD and has been determined by CMS to be reasonable and necessary for the 
management of the enrollee's advanced cancer. The Plan denied your request. The Plan says HCPC code 
0037U and diagnosis code C77.9 do not meet medical necessity. 
 
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 pay for the genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the HCPC 0037U and diagnosis code C77.9 did not meet medical necessity. The review has determined that the items/services at issue in this case are 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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for FoundationOne CDx (F1CDx) test (0037U) provided April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on December 6, 2021 to 
December 13, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chiropractic services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as prior 
authorization was not obtained, your primary care physician (PCP) referred you to an in-network provider but 
you went to an out-of-network provider instead. 
 
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 chiropractic services provided on December 6, 
2021 to December 13, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 18, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that this was a medically appropriate visit. The Plan 
denied your request. The Plan says this provider is not a network provider with the Plan. The Plan also says 
that they have also determined that these services are not urgent or emergent, nor were they approved in 
advance. 
 
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 an office visit provided on March 18, 2022, by an 
out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 
You asked the Plan to pre-approve Synvisc. 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 follows Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via intra-
articular injections of hyaluronic preparations will be considered medically reasonable and necessary when 
specific criteria are met. 
 
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 Synvisc. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, at least 6 months have not yet 
elapsed since the prior series of injections. The review has determined that you do not meet the coverage 
criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the myocardial perfusion imaging, 
tomographic (SPECT) test, Cardiovascular stress test, and metoclopramide injection (J2765, 93015, 78452) 
provided on July 26, 2021. 
 
You asked the Plan to waive the deductible for the myocardial perfusion imaging, tomographic (SPECT) test, 
Cardiovascular stress test, and metoclopramide injection. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly based 
on the services provided. 
 
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 a $750 deductible and a 20% coinsurance which applies to Outpatient 
diagnostic tests and therapeutic services and supplies Medicare Part B prescription drugs.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
diagnostic tests and therapeutic services. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $750 deductible which applies to Outpatient diagnostic tests and therapeutic services. 
This cost sharing is a contractual obligation that had not been met at the time the myocardial perfusion 
imaging, tomographic (SPECT) test, Cardiovascular stress test, and metoclopramide injection was received on 
July 26, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the myocardial 
perfusion imaging, tomographic (SPECT) test and a Cardiovascular stress test (93015, 78452) provided on July 
26, 2021.  
 
You have also been asked to pay a 20% coinsurance for the metoclopramide injection (allowed amount is $238.20 x 
20% = $47.64). 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) provided on 
March 29, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hospital outpatient clinic visit. You say that the enrollee felt their questions 
were not being answers by their in-network physician. The Plan denied your request. The Plan says the service 
was provided out-of-network and was not approved in advance. 
  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 hospital outpatient clinic visit (G0463) 
provided on March 29, 2022, by an out-of-network (OON) provider.