Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on June 14, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that you are requesting reconsideration stating the 
visit was medically necessary for assessment and evaluation of lower extremities. 
 The Plan denied your request. The Plan says the enrollee must receive their care from a network provider (for 
more information about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an 
out-of-network provider (a provider who is not part of our plans network) will not be covered. 
 
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 home health services provided on June 14, 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 outpatient hospital surgery service provided 
on May 24, 2022. 
 
You asked the Plan to waive the copayment for hospital surgery. You say that you cannot afford 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 $200 
copayment for outpatient hospital surgery service.  
 
You have been asked to pay $200 copayment for hospital surgery. This item/service falls within the outpatient 
hospital surgery 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 
hospital surgery service provided on May 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab tests provided on May 03, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for lab tests. You say that you are requesting reconsideration because there was no 
payment on this claim. The provider would like the claim to be reprocessed and paid. The Plan denied your 
request. The Plan says the enrollees network primary care physician (PCP) or plan must give the enrollee 
approval in advance before they can use providers not in the plan's network. This is called giving you a 
"referral." 
 
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 lab tests provided on May 03, 2022, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services coded 62320 provided on June 16, 
2022. 
 
You asked the Plan to pay for the injection services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested services are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that injection services without imaging guidance is 
not covered.  
 
We looked at the file and Medicare rules. Review of the file shows that the code at issue (62320) is specifically 
not covered. Based on this information, we decided that Medicare rules for coverage of the injection services 
have not been met. Therefore, we decided that the Plan does not have to pay for the injection services coded 
62320 provided on June 16, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx testing (0037U) provided May 3, 2022. 
 
You asked the Plan to pay for F1CDx testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says that the date-of-service should be reported as the date the specimen was 
collected. 
 
The Plan must follow Medicare rules. Medicare rules say that the FoundationOne CDx test is covered when it 
is FDA approved for the enrollees diagnosis. 
 
We looked at the file and Medicare rules. In this case the laboratory test performed is considered an ADLT. 
The sample in this case was collected during a hospital outpatient counter. Therefore, the date-of-service was 
correctly reported as the date the test was performed, May 3, 2022. Additionally, documentation shows that the F1CDx test was performed for the enrollees solid tumor. Solid tumors are a covered indication for F1CDx. 
Based on this information, we decided that Medicare rules for coverage of F1CDx testing have been met. 
Therefore, we decided that the Plan has to pay for the FoundationOne CDx testing (0037U) provided May 3, 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 28, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99100 is considered bundled and 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 procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service April 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infusion services provided on February 10, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the infusion services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says a referral/authorization was not obtained prior to services being 
rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for infusion services provided on February 10, 2021, 
by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 70450 and 70486 billed for date of service 
April 26, 2022. 
 You asked the Plan to pay for procedure codes 70450 and 70486. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for codes 70450 and 70486 is bundled into 
payment for code 78816. 
 
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 
and 70486 is a column II code to column I code 78816. 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 codes 70450 and 70486 billed for date 
of service April 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient diagnostic test provided on 
April 19, 2022. 
 
You asked the Plan to waive the coinsurance for x-ray exam. You say that you were requesting to dispute a 
coinsurance 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 $6.99 
coinsurance for Medicare-covered X-rays. The allowed amount of the diagnostic test total $34.94, resulting in a 
total coinsurance amount of $6.99. 
 
You have been asked to pay $6.99 coinsurance for x-ray exam. This item/service falls within the Medicare-
covered X-rays 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 outpatient diagnostic test 
provided on April 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nuvasive Osteocel allograft. 
 
You asked the Plan to pre-approve Nuvasive Osteocel allograft. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 Nuvasive Osteocel allograft. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception. Therefore, the requested Nuvasive 
Osteocel allograft, 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 Nuvasive Osteocel allograft have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Nuvasive Osteocel allograft.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-ray services provided on February 1, 
2022. 
 
You asked the Plan to waive the copayment for x-ray services. You say that the x-rays should have been paid 
for in the first 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 a $40 
copayment for basic radiological services in a specialist office.  
 
You have been asked to pay a $28.76 copayment for x-ray services. This item/service falls within the basic 
radiological services in a specialist office benefit category. The allowed amount is lower than your copayment.  
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-ray services provided on February 1, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physician visit provided on April 20, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a physician visit. You say that you are appealing denied services because you 
provided assisted living care for member in good faith. The Plan denied your request. The Plan says no 
authorization was obtained prior to physician visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a physician visit provided on April 20, 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 diagnostic injections provided on June 13, 
2022. 
 
You asked the Plan to waive the copayment for diagnostic injections. You say that you were unaware of this 
copayment, and the treatment did not work. 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 $290 
copayment for outpatient surgery. 
 
You have been asked to pay a $290 copayment for diagnostic injections. This item/service falls within the 
outpatient surgery 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 diagnostic injections 
provided on June 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry 
(83789) provided on June 14, 2022. 
 
You asked the Plan to pay for procedure code 83789. 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 performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 83789 have not been met. Specifically, we find that the testing described by the 
billed code is considered specimen validity testing which is not separately payable. Therefore, we decided that 
the Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry (83789) provided on 
June 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve Ozempic. You say that you would like the Plan to reconsider their denial. 
The Plan denied your request. The Plan says Ozempic is not covered under your Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ozempic.  
 
Benefits for Ozempic may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visits provided on April 
01, 2022, to May 27, 2022. 
 
You asked the Plan to waive the copayment for specialist office visits. You say that this should be going 
through the hospital. The only reason for these visits is becuase of a surgical error. 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 $45 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $45 copayment for specialist office visits. This item/service falls within the 
physician/practitioner services, including doctors 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. You had three visits, each with a $45 copayment 
($45 x 3 visits = $135). Therefore, we decided that the Plan does not have to waive the copayment for specialist 
office visits provided on April 01, 2022, to May 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lidocaine HCL Viscous. 
 
You asked the Plan to pre-approve Lidocaine HCL Viscous. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says Lidocaine HCL Viscous is not covered under the 
enrollee's Medicare Part B benefit. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lidocaine HCL Viscous.  
 
Benefits for Lidocaine HCL Viscous may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a pulmonology visit, and an airflow test 
provided on May 27, 2022. 
 
You asked the Plan to waive the copayment for a pulmonology visit and an airflow test. You say that you 
should not have these copayments. 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 $20 
copayment for physician/practitioner services, including doctor's office visits and a $20 copayment for 
outpatient diagnostic tests and therapeutic services and supplies ($20 x 2 services = $40).  
 
You have been asked to pay a $40 total copayment for a pulmonology visit and an airflow test. This 
item/service falls within the physician/practitioner services, including doctor's office visits and 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 a pulmonology visit, and an airflow test 
provided on May 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies provided on 
March 10, 2022. 
 
You asked the Plan to pay for the CGM supplies. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the documentation does not support the relationship between the referring 
provider and the enrollee. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.   
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Review of the file does not support an established relationship between the referring provider and 
the enrollee. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor 
(CGM) supplies provided on March 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a back brace provided on May 2, 2022. 
 
You asked the Plan to waive the coinsurance for a back brace. You say that this brace should not cost as much 
as the provider charged. 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 20% 
coinsurance for durable medical equipment and supplies.  
 
You have been asked to pay 20% coinsurance for a back brace. This item/service falls within the durable 
medical equipment 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 coinsurance for a 
back brace provided on May 2, 2022.  
 Your complaint about the cost of the brace and the possibility you never needed it is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.