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

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic test provided on May 
4, 2022. 
 
You asked the Plan to waive the copayment for outpatient diagnostic test. You say that you are disputing the 
amount assessed by the health Plan for the copayment. The Plan denied your request. The Plan says this cost 
sharing was charged 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 $60 
copayment for Medicare-covered radiation therapy service.  
 
You have been asked to pay $48.91, which is less than the $60 copayment for outpatient diagnostic test. This 
item/service falls within the Medicare-covered radiation therapy service 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 outpatient diagnostic test provided on May 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder Detect testing (0012M) provided on 
December 16, 2021. 
 
You asked the Plan to pay for the Cxbladder Detect testing. You say that this test was medically necessary and 
is covered. The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder Detect testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the Cxbladder Detect testing (0012M) provided on December 16, 
2021.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve an attended split-night polysomnography (PSG) (95811). 
 
You asked the Plan to pre-approve an attended split-night PSG. You say that an in-lab split-night study is 
medically necessary because of the recurrence of symptoms. The Plan denied your request. The Plan says that a 
facility-based sleep study is not needed because the enrollee's OSA was confirmed in the past. 
 
The Plan follows Medicare rules. Medicare rules say that a polysomnography with PAP titration is indicated in 
patients with sleep apnea previously diagnosed by a clinical evaluation and either a positive PSG or a positive 
HST. 
 
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 an attended split-night PSG. Our 
reviewer says that a split-night PSG with positive airway pressure (PAP) titration is reasonable and medically 
necessary. Our physician reviewer found this enrollee has a diagnosis of Obstructive Sleep Apnea (OSA) made 
in 2015. Our reviewer found that the enrollee has benefited from consistent use of auto-titrating continuous 
positive airway pressure (CPAP), but symptoms of fatigue and non-restful sleep have recurred. Our reviewer 
also found that it is therefore reasonable to repeat the PSG along with PAP titration to re-confirm the diagnosis 
and identify optimal PAP settings. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an attended split-night PSG have been met. Therefore, we decided that the Plan 
has to pre-approve an attended split-night polysomnography (PSG) (95811).  
 
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 infrared therapy provided on April 27, 2022. 
 
You asked the Plan to pay for infrared therapy. The Plan denied your request. The Plan says infrared therapy is 
considered not reasonable and necessary by Medicare and is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to conclude the use of 
infrared therapy devices and any related accessories is not reasonable and necessary under section 
1862(a)(1)(A) of the Social Security Act (the Act). 
 
We looked at the file and Medicare rules. Medicare says say that there is sufficient evidence to conclude the 
use of infrared therapy devices and any related accessories is not reasonable and necessary. Therefore, we 
decided that the Plan does not have to pay for infrared therapy provided on April 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G assist orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the enrollee has been referred by their 
physician assist for myoelectric orthotic restoration using the MyoPro Motion G. The Plan denied your request. 
The Plan says this item is considered experimental and investigational. There is insufficient evidence of its 
effectiveness. This provider does not participate with Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules say that Medicare payment cannot be made to a provider that is not 
enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. Review of the file and Medicare records indicates that the provider at 
issue is not enrolled in the Medicare program. Based on this information, we decided that Medicare rules for coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro Motion G assist orthotic device (L8702).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 
You asked the Plan to pre-approve Ilumya. You say that the required drugs will not work for the enrollee. The 
Plan denied your request. The Plan says step therapy requirements have not been met. 
 
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 Ilumya. Our reviewer says that the 
requirements for coverage of Ilumya have not been met. Our physician reviewer found the Plan requires a trial 
of Remicade or Avsola before they will approve the requested drug. The records do not show the enrollee has 
tried either of these drugs, that these drugs would likely be less effective, or that these drugs would have 
adverse effects 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 Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 12, 2022, 
through January 27, 2022. 
 
You asked the Plan to pay for the home health services. You say that you have been reimbursed for multiple 
clients where only a RAP was sent, and you were never notified that an NOA was a requirement. You say that 
services were provided in good faith with the expectation of being reimbursed. The Plan denied your request. 
The Plan says a valid NOA is required to process a claim. 
 
The Plan must follow Medicare rules. Medicare rules say that home health services under a plan of care are 
paid based on a 30-day period of care. HHAs submit an NOA at the beginning of an admission and then submit 
one claim for each 30-day period of care. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, a valid NOA was not submitted. 
Therefore, we decided that the Plan does not have to pay for the home health services provided from January 
12, 2022, through January 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote physiologic monitoring treatment management 
services provided on April 30, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for remote physiologic monitoring treatment management services. You say that the 
procedure was done in reference to an annual physical. The Plan denied your request. The Plan says the 
services were provided out-of-network and were not approved in advanced. 
 
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 remote physiologic monitoring treatment 
management services provided on April 30, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on July 25, 
2022. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you were charged a second 
copayment when you went to your provider for a follow-up appointment. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for urgently needed services. 
 
You have been asked to pay a $40 copayment for an urgent care visit. This item/service falls within the 
urgently needed 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 an urgent 
care visit provided on July 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 4, 2021, to July 
7, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
services at issue were billed correctly. The Plan denied your request. The Plan says rules for payment at the 
DRG originally billed have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code, A41.9, defined as Sepsis, 
unspecified organism. 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 inpatient hospital 
services at the DRG originally billed. Our reviewer says that the services at issue do not meet criteria for 
payment at the DRG originally billed. Our physician reviewer found the available medical records do not 
support DRG 871 and principal diagnosis code A41.9.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on July 4, 2021, to July 7, 2021, at the DRG originally billed.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
and the basic support routine supplies (A0382) provided on January 26, 2022. 
 
You asked the Plan to pay for the ambulance response and supplies. You say that you did not need to be 
transported. The Plan denied your request. The Plan says these services are not covered when there is no 
transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.   
The ambulance company did not provide transport services on January 26, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) and the basic support routine supplies (A0382) provided on January 26, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for injection(s), anesthetic agent(s) and/or steroid; genicular nerve 
branches, including imaging guidance (CPT 64454) provided on January 19, 2022. 
 
You asked the Plan to pay for injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, 
including imaging guidance. You say that the medical records support coverage. The Plan denied your request. 
The Plan says that part of primary procedure ineligible for separate pay. 
 
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. Specifically, the Plan has not provided us with a Medicare rule to support their 
denial. Therefore, we decided that the Plan has to pay for injection(s), anesthetic agent(s) and/or steroid; 
genicular nerve branches, including imaging guidance (CPT 64454) provided on January 19, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on March 26, 
2022. 
 
You asked the Plan to waive the copayment for emergency care. You say that you are filing this appeal for 
reimbursement of your visit. The Plan denied your request. The Plan says this cost sharing was charged 
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 $90 
copayment for emergency care visit.  
 
You have been asked to pay $90 copayment for emergency care. This item/service falls within the emergency 
care visit 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 emergency care provided 
on March 26, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on June 13, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you feel 
this claim should be approved for coverage because the paramedics transported you home instead of to the 
emergency room. The Plan denied your request. The Plan says this service was not paid because it is not 
reimbursable. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 13, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on June 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (K0553) provided on February 
8, 2022. 
 
You asked the Plan to pay for the continuous glucose monitor. You say that the item was medically necessary. 
The Plan denied your request. The Plan says durable medical equipment for use when the enrollee is a Part A 
covered inpatient is not paid separately. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the continuous glucose monitor was used in a SNF or hospital. Therefore, we decided that 
the Plan does not have to pay for a continuous glucose monitor (K0553) provided on February 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88341, 88342, 88381, 88360) provided on 
February 2, 2022. 
 
You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid 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. 
 
We find that CPT codes 88341, 88342, 88381, and 88360 are not supported in the medical record. Specifically, 
these codes have a professional component / technical component indicator of 1 per the National Physician Fee 
Schedule. The claim is billed with place of service 21, inpatient hospital, but was not billed with the required 
Modifier 26. 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 (88341, 88342, 88381, 
88360) provided on February 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-share for a PET scan provided on March 17, 2022. 
 
You asked the Plan to waive the cost-share for a PET scan. You say that you are requesting reconsideration 
because you feel the claim was coded incorrectly. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for advanced imaging services in an outpatient hospital and 20% coinsurance for radiation therapy 
including technician materials and supplies.  
 
 
  You have been asked to pay a $275 copayment for a PET scan and a coinsurance of $922.14, which is 20% of 
the allowed amount for radiation therapy including technician materials and supplies ($4,610.68 allowed 
amount x 20% = $922.14). These items/services 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 cost-share for a PET scan 
provided on March 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99204) provided on April 6, 2022. 
 
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 the records do not support the code 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, the CPT Code Manual definition of code 99204 is Office or other outpatient visit for the 
evaluation and management of a new patient. 
 
We find that CPT code 99204 is not supported in the medical record. Specifically, records show this was an 
established patient. Code 99205 was previously billed for the enrollee on September 1, 2021 by the same 
physician group.. Based on this information, we decided that Medicare rules for coverage of the physician 
services have not been met. Therefore, we decided that the Plan does not have to pay for physician services 
(99204) provided on April 6, 2022.