Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sensor (A9276) and monitor (A9278) for a continuous 
glucose monitoring system. 
 
You asked the Plan to pre-approve sensor and monitor for a continuous glucose monitoring system. You say 
that the items are necessary. The Plan denied your request. The Plan says codes A9276 and A9278 have a 
status indicator of I, which indicates that this service is not valid for Medicare purposes. Therefore, coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services 
performed.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage for a sensor and monitor for a continuous glucose monitoring system billed under codes A9276 and 
A9278 have not been met. Therefore, we decided that the Plan does not have to pre-approve sensor (A9276) 
and monitor (A9278) for a continuous glucose monitoring system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits (99203, 99213, 99214) rendered by the out-
of-network (OON) provider from November 30, 2021, through January 11, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. 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 the office visits (99203, 99213, 99214) rendered by the out-of-network (OON) 
provider from November 30, 2021, through January 11, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an ultrasound (51798) provided on May 11, 
2021. 
 
You asked the Plan to waive the deductible for the ultrasound. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the deductible 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 $150 deductible which applies to Outpatient diagnostic tests and 
therapeutic services and supplies.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $150 deductible which applies to Outpatient diagnostic tests and 
therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time 
the ultrasound was received on May 11, 2021. Therefore, we decided that the Plan does not have to waive the 
deductible for an ultrasound (51798) provided on May 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an arthrocentesis procedure (20610) 
provided on October 15, 2021. 
 
You asked the Plan to waive the copayment for the arthrocentesis procedure. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $370 
copayment for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 You have been asked to pay a $303.06 copayment for the arthrocentesis procedure, which is less than the 
standard $370. Arthrocentesis procedures fall within the Outpatient Surgery and Other Medical Services 
Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 arthrocentesis procedure (20610) provided on October 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on November 1, 
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 separately billed services/tests have been bundled as they are considered components of the same 
procedure. 
 
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 72114 is "Radiologic examination, spine, lumbosacral; 
complete, including bending views, minimum of 6 views." 
 
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 not supported by the medical records.  
 Our reviewer found the provider performed an x-ray on entire spine, and billed CPT 72082 and CPT 72114 are 
both column 2 codes to the scoliosis evaluation codes. CPT 72114 is x-ray of lumbosacral spine, which would 
be inclusive to CPT 72082 of the entire spine. 
 
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 imaging services provided to the enrollee on November 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on August 5, 2021, by an out-of-
network (OON) provider. 
 
 
 You asked the Plan to pay for the office visit. You say that you are requesting a reconsideration for the enrollee 
to have a pre-authorization for this service. 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 the office visit provided on August 5, 2021, by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reduce the cost share for pacemaker evaluation provided on January 3, 2022, 
and January 6, 2022. 
 
You asked the Plan to reduce the cost share for the pacemaker evaluations. You say that the service on January 
3, 2022, was done remotely. You also say that you do not understand why the insurance company has not paid 
a cent on these claims. The Plan denied your request. The Plan says that 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. Your 
contract with the Plan says that enrollees must pay 40% coinsurance for an out-of-network prosthetic device 
evaluation.  
 
The Plan says you must pay $37.75 for the pacemaker evaluation on January 3, 2022. The Plan also says you 
must pay $15.10 for the pacemaker evaluation on January 6, 2022.  Based on the Plan contract, however, you 
cannot be asked to pay more than 40% coinsurance of the allowed amount for pacemaker evaluations. 
Therefore, we decided that the Plan has to reduce the cost share for pacemaker evaluation provided on January 
3, 2022, and January 6, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no indication that this patient is enrolled in a clinical trial of the device. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes 
establishing the value of CardioMEMS in patient management. As a result, at this time the CardioMEMS 
system would not be considered medically appropriate and necessary in this patients clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth services rendered on September 17, 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 procedure code 99441 is not supported. 
 
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 99441 is telephone evaluation and management service 
by a physician or other qualified health care professional who may report evaluation and management services 
provided to an established patient, parent, or guardian not originating from a related E/M service provided 
within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest 
available appointment; 5-10 minutes of medical discussion. 
 We find that CPT code 99441 is not supported in the medical record. Specifically, the file shows that the 
services originated from an evaluation and management service billed with code 99214 on September 15, 2021. 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the telehealth services rendered on September 17, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the ventilator is not medically necessary. Our physician reviewer found Medicare does not pay for a home 
ventilator when used as a BIPAP. There is no evidence of failure of BIPAP at home. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Genetic Testing provided on December 14, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Genetic Testing. 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 it was 
determined these services can be received in-network. 
 
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 Genetic Testing provided on December 14, 2021 
by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on February 
14, 2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you needed to be transferred 
to a different hospital and were called an ambulance. You also say your wife could have driven you, but you 
were not given any options. 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 $250 
copayment for ground ambulance services.  
 
You have been asked to pay a $250 copayment for ambulance services. Ambulance services falls within the 
Ambulance Services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services 
provided on February 14, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Psychotherapy provided on August 2, 2021 to August 4, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Psychotherapy. You say that you would like to request reconsideration for 
payment. 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 Psychotherapy provided on August 2, 2021 to 
August 4, 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 a comprehensive examination provided from January 20, 
2022, to January 27, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a comprehensive examination. You say that you should be covered under any 
authorization for the nursing home. The Plan denied your request. The Plan says this provider is not a network 
provider with the Plan, and the services were not referred by a network provider or rendered in an in-network 
facility. The Plan has 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 a comprehensive examination provided from 
January 20, 2022, to January 27, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost for the myocardial perfusion imaging and 
regadenoson injection provided on January 11, 2022. 
 
You asked the Plan to reduce the cost for the myocardial perfusion imaging and regadenoson injection. You 
say that you should only be charged the copayment for the sleep study and not the coinsurance for the injection. 
You say that the services should have been tied together as the injection was related to part of the sleep study. 
The Plan denied your request. The Plan says you have been charged the correct 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 20% 
coinsurance for chemotherapy drugs, infusion drugs, and all other covered under Medicare Part B. Your 
contract with the Plan clearly says that you must pay a $50 copayment for diagnostic procedures and tests. 
 
You have been asked to pay a total of $97.76 for the myocardial perfusion imaging and regadenoson injection.  
 
Service Allowed Amount Standard Cost Member Liability 
Myocardial Perfusion Imaging $462.09 $50 $50 
Regadenoson Injection $238.80 20% $47.76 
TOTAL:   $97.76 
 
The myocardial perfusion imaging falls within the Outpatient diagnostic tests and therapeutic services and 
supplies benefit category. The regadenoson injection falls within the Medicare Part B prescription drugs 
category. Medicare Part B drugs are considered a separate service. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the 
cost for the myocardial perfusion imaging and regadenoson injection provided on January 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for acupuncture services (97813) provided on 
December 21, 2021, to January 11, 2022. 
 
You asked the Plan to waive the copayment for the acupuncture services. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for Acupuncture for chronic low back pain.  
 
 
  You have been asked to pay a $140 copayment for 4 acupuncture visits ($35 x 4 =$140). 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 acupuncture services (97813) provided on December 21, 2021, to 
January 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Domicile Home Visit provided on February 1, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Domicile Home Visit. You say that the services provided were medically 
necessary. 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 Domicile Home Visit provided on February 1, 
2022 by an out-of-network (OON) provider.