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

We decided that the Plan does not have to waive the copayment for the office visit (99213) and the transvaginal
ultrasound (76830) provided on June 7, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has 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 $40
copayment for services obtained from a specialist.
Additionally, you must pay a $105 copayment for Medicare-covered radiological diagnostic services, not
including x-rays, performed in a physician's office or at a free standing facility (such as a radiology center or
medical clinic).
You have been asked to pay a $145 copayment for the specialist office visit and the Medicare-covered
radiological diagnostic service provided. 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 office
visit (99213) and the transvaginal ultrasound (76830) provided on June 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 2, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Review of the file shows the claim was billed with an inappropriate place of service 11. According to claims history, the specimen was obtained in a Skilled Nursing Facility POS 31. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the targeted genomic sequence analysis (0037U) rendered by 
the out-of-network (OON) provider on July 29, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.

We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the targeted genomic sequence analysis (0037U) rendered by the out-of-network 
(OON) provider on July 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the antigen injections you received on March 11, 2021, and March 12, 2021.
You asked the Plan to waive the coinsurance for the antigen injections. You say that you were told this would be covered in full as immunotherapy. The Plan denied your request. The Plan says you were charged this coinsurance 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 20%
coinsurance for Medicare Part B drugs (including antigens).
You have been asked to pay 20% coinsurance for the antigen injections. The antigen injections fall within the
Medicare Part B 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 the antigen
injections you received on March 11, 2021, and March 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 9, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 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 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 the laboratory services provided on February 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve the Vertiflex procedure. You say that this request is medically reasonable
and necessary. 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 Vertiflex procedure. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the Vertiflex 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve the Vertiflex procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an audiologist visit provided on by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the audiologist visit. You say that your visits have always been covered. The 
Plan denied your request. The Plan says no prior authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for an audiologist visit provided on by an out-of-network (OON) 
provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan (J7321).
You asked the Plan to pre-approve Hyalgan. You say that the requested drug is medically necessary. The Plan
denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Monovisc and
Orthovisc.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Hyalgan. Our reviewer says that Hyalgan is not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee has tried and failed the required drugs, Monovisc and Orthovisc. The reviewer also found that the documentation does not outline contraindications or reasons these medications were not considered or that the Plan's additional required drug would likely be less effective and/or likely have adverse effects for the enrollee. Without the support of the documentation, Hyalgan is not approved, as step criteria have not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hyalgan have not been met. Specifically, the file does not indicate that the enrollee has tried and failed the required drugs. Therefore, we decided that the Plan does not have to pre-approve Hyalgan (J7321).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint injection.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says there are no exam findings in the record documenting sacroiliac pain.
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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, the record indicates that the enrollee was treated for hip pain and cervical neck pain. The record provided does not provide any documentation of a sacroiliac disorder. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint injection.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound services represented by code 76775 provided on March 7, 2021.
You asked the Plan to pay for code 76775. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
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 76775
is a column II code to column I code 76770. 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 the ultrasound services represented by code 76775 provided on March 7, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 10, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service
(POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on February 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion interspinous device. 
 
You asked the Plan to pre-approve Vertiflex Superion interspinous device. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not 
medically necessary. 
 
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 Vertiflex Superion interspinous device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found you were being treated for spinal stenosis, lumbar region, without 
neurogenic claudication. However, there are no objective findings provided on any recent exams to corroborate 
the pathology. In addition, current evidence based medical guideline and peer reviewed literature do not fully 
support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a 
lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for your 
medical condition as discussed above. FDA indications include implantation of the Superion device at one or 
two adjacent lumbar levels in enrollees with moderate spinal stenosis in whom operative treatment is indicated 
at no more than two levels, from L1 to L5. You have multiple degrees of spinal stenosis, many not at FDA 
indicated levels of "moderate" spinal stenosis (including the planned level of implantation L3-4). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex Superion interspinous device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Vertiflex Superion interspinous device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that the requested procedure is medically 
reasonable and necessary. 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 Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Medicare criteria for reasonable and necessary are not met as the Vertiflex 
procedure has not been shown to be safe and effective in long term studies. There is a lack of evidence to 
support that the interspinous spacer devices are as safe and effective gold standard of decompression. 

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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from November 1, 2021, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from November 1, 2021, forward. You say that 
the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue 
are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from 
November 1, 2021, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental 
health treatment beyond the date in question of November 1, 2021, forward. Our physician reviewer found you 
did not require inpatient mental health treatment beyond November 1, 2021, as you were not a danger to 
yourself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active 
treatment was taking place beyond the date in question. It did not appear that the services for the dates in 
question were reasonably expected or medically necessary to improve your condition or for the purpose of 
diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from November 1, 2021, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from November 1, 
2021, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the specialist services rendered on June 10, 
2021. 
 
You asked the Plan to waive the deductible for these services. You say that you disagree with the charges. The 
Plan denied your request. The Plan says the deductible was applied correctly. 
 
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 $1,500 yearly deductible which applies to your covered medical 
services.  
 
The item or service you asked the Plan to waive the deductible for falls within the out-of-network specialist's 
office services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is $1,500 yearly deductible which applies to your covered medical services.

This cost sharing is a contractual obligation that had not been met at the time these services were received on 
June 10, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the specialist 
services rendered on June 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care services (11045 and 11047) provided on 
March 17, 2021. 
 
You asked the Plan to pay for the wound care services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must confirm that Medicare 
coverage criteria have been met. 
  
We looked at the file and Medicare rules. In this case, there were no medical records provided confirming that 
1 unit of debridement with code 11045 and 12 units of debridement with code 11047 were provided on March 
17, 2021. Therefore, we decided that the Plan does not have to pay for the wound care services (11045 and 
11047) provided on March 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 8, 2020. 
 
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 claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on October 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on June 22, 2021.
You asked the Plan to pay for a CT scan. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says this is not separately payable.
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 a computed tomography (CT) scan (70450) provided on June 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for pulmonary rehabilitation services you 
received on May 28, 2021, and June 24, 2021. 
 
You asked the Plan to waive the deductible for the pulmonary rehabilitation services. You say that you were 
told that there would be no charge for this service.  You also stated that you had this service years ago and 
didn't have to pay anything. The Plan denied your request. The Plan says you had not yet met your deductible 
at the time of these services, so you were charged this amount correctly. 
 
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 which applies to pulmonary rehabilitation services.  
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which 
applies to pulmonary rehabilitation services. This cost sharing is a contractual obligation that had not been met 
at the time the pulmonary rehabilitation services were received on May 28, 2021, and June 24, 2021. Therefore, 
we decided that the Plan does not have to waive the deductible for pulmonary rehabilitation services you 
received on May 28, 2021, and June 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical procedures represented by codes 20930 and 20936 provided on March 30, 2021.
You asked the Plan to pay for codes 20930 and 20936. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Codes 20930 and 20936 have a status code of "B" under the Medicare Physicians Fee Schedule Database (MPFSDB) and no separate payment is made for these codes under the fee schedule as payment is bundled into the payment for the services to which these codes are incident to. Therefore, we decided that the Plan does not have to pay for the surgical procedures represented by codes 20930 and 20936 provided on March 30, 2021.