Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram (ECG) monitoring and analysis 
provided on November 12, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the ECG monitoring and analysis. You say that the enrollee was seen by a 
provider who is in-network. You say you are a third party and usually fall under the authorization of the 
referral source. The Plan denied your request. The Plan says the provider is out-of-network, and 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 
ECG monitoring and analysis. We found no exception that would require the Plan to pay for the ECG 
monitoring and analysis. The records provided for review do not show that the ECG monitoring and analysis 
was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the electrocardiogram 
(ECG) monitoring and analysis provided on November 12, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on December 3, 
2021. 
 
You asked the Plan to pay for the services. You say that the medical records do not indicate adjuvant platinum-
containing chemotherapy is being considered for the patient. The Plan denied your request. The Plan says the 
medical records do not indicate adjuvant platinum-containing chemotherapy is being considered for the patient. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found DetermaDx is a molecular test for non-small cell lung cancer that is used to stratify patients with stage I 
and IIA non-squamous cell non-small cell lung cancer who may benefit from adjuvant chemotherapy. It is not a standard of care. Its use is not supported by the National Comprehensive Cancer Network (NCCN) guidelines, 
which instead advises decisions to be made based on pathologic features. The service is not reasonable or 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on December 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the pain management injection provided at 
an ambulatory surgical center on January 26, 2022. 
 
You asked the Plan to waive the copayment for the pain management injection. You say that you have paid a 
$250 copayment for this service in the past. The Plan denied your request. The Plan says the copayment 
amount charged is correct. 
 
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 $300 
copayment for per visit at an ambulatory surgical center.  
 
 
 You have been asked to pay a $300 copayment for the pain management injection. A pain management 
injection falls within the Outpatient Surgery, Including 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 the pain 
management injection provided at an ambulatory surgical center on January 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraspinal chiropractic manipulative treatment (code 
98943) and the electrical stimulation (code G0283) provided by a chiropractor on December 13, 2021. 
 
You asked the Plan to pay for the chiropractic services.. You say that these services were medically necessary. 
The Plan denied your request. The Plan says these are not Medicare-covered chiropractic services.  While the 
member does have a supplemental chiropractic benefit for non-Medicare covered chiropractic services, the 
member has exhausted that benefit for 2021. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. The Plan does have a 
supplemental chiropractic benefit that will cover chiropractic services beyond manual manipulation of the spine.  This benefit is limited to 30 visits each calendar year.  Records show that the member exhausted this 30-
visit maximum on December 3, 2021, so no additional non-Medicare covered chiropractic services are eligible 
for coverage after that date. Therefore, we decided that the Plan does not have to pay for the extraspinal 
chiropractic manipulative treatment (code 98943) and the electrical stimulation (code G0283) provided by a 
chiropractor on December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraspinal chiropractic manipulative treatment (code 
98943) and the electrical stimulation (code G0283) provided by a chiropractor on December 16, 2021. 
 
You asked the Plan to pay for the chiropractic services.. You say that these services were medically necessary. 
The Plan denied your request. The Plan says these are not Medicare-covered chiropractic services.  While the 
member does have a supplemental chiropractic benefit for non-Medicare covered chiropractic services, the 
member has exhausted that benefit for 2021. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. The Plan does have a 
supplemental chiropractic benefit that will cover chiropractic services beyond manual manipulation of the spine.  This benefit is limited to 30 visits each calendar year.  Records show that the member exhausted this 30-
visit maximum on December 3, 2021, so no additional non-Medicare covered chiropractic services are eligible 
for coverage after that date. Therefore, we decided that the Plan does not have to pay for the extraspinal 
chiropractic manipulative treatment (code 98943) and the electrical stimulation (code G0283) provided by a 
chiropractor on December 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the Part B drug injection provided by a 
network facility on February 1, 2022. 
 
You asked the Plan to reduce the coinsurance for the Part B drug injection. You say that you were told you 
would only have a $10 copayment. You say your bones will shatter if you stop receiving the injection, and you 
cannot afford it. The Plan denied your request. The Plan says you have been asked to pay 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 20% 
coinsurance for Medicare Part B chemotherapy drugs, associated administration services and all other 
Medicare Part B drugs.   
You have been asked to pay $254.46 which is 20% of the allowed amount for the Part B drug injection. The 
allowed amount is $1,272.30. ($1,272.30 x 20% = $254.46). The Part B drug injection falls within the 
Medicare Part B prescription 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 reduce the coinsurance for 
the Part B drug injection provided by a network facility on February 1, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided September 8, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that while exiting a restaurant you fell and 
someone called for an ambulance. They responded, checked for injuries and cleared you to go home with no 
follow up. There was no reason to go to the hospital. The Plan denied your request. The Plan says this service 
is not a covered benefit. 
 
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 September 8, 2021. 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 ambulance response and treatment, no transport 
(A0998) provided September 8, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy performed on November 18, 
2021. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that the service is preventive and you 
should not have a copayment. 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 no coinsurance, copayment, or deductible for colorectal screening exams. 
 
Your contract with the Plan also clearly says that you must pay a $200 copayment per visit for surgery or 
services provided at an ambulatory surgical center. 
 
The file shows that a biopsy was taken during the procedure. This tissue removal makes the procedure 
diagnostic and surgical in nature, and is no longer a screening. Therefore, you have been asked to pay a $200 
copayment for the colonoscopy. The colonoscopy falls within the Outpatient Surgery, Including 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 a colonoscopy performed on November 18, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic hearing evaluation (code 
92557) provided on May 18, 2021. 
 
You asked the Plan to waive the copayment for the diagnostic hearing evaluation (code 92557). You say that 
the copayment should be $0. The Plan denied your request. The Plan says the copayment amount charged is 
correct. 
 
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 each Medicare-covered diagnostic hearing exam.  
 
 
 
 
  
You have been asked to pay a $10 copayment, which is less than the Plan's EOC documented $40 copayment 
for a diagnostic hearing evaluation (code 92557). A diagnostic hearing evaluation (code 92557) falls within the 
Hearing 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 the diagnostic 
hearing evaluation (code 92557) provided on May 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraspinal chiropractic manipulative treatment (code 
98943) and the electrical stimulation (code G0283) provided by a chiropractor on December 8, 2021. 
 
You asked the Plan to pay for the chiropractic services.. You say that these services were medically necessary. 
The Plan denied your request. The Plan says these are not Medicare-covered chiropractic services.  While the 
member does have a supplemental chiropractic benefit for non-Medicare covered chiropractic services, the 
member has exhausted that benefit for 2021. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 The records show that the services at issue are not manual manipulation of the spine. The Plan does have a 
supplemental chiropractic benefit that will cover chiropractic services beyond manual manipulation of the 
spine.  This benefit is limited to 30 visits each calendar year.  Records show that the member exhausted this 30-
visit maximum on December 3, 2021, so no additional non-Medicare covered chiropractic services are eligible 
for coverage after that date. Therefore, we decided that the Plan does not have to pay for the extraspinal 
chiropractic manipulative treatment (code 98943) and the electrical stimulation (code G0283) provided by a 
chiropractor on December 8, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on January 25, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that the patient was in a nursing facility and 
should not have needed an authorization. The Plan denied your request. The Plan says the services were 
provided out-of-network and were not approved in advance. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for home health services provided on January 25, 
2022 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Clenpiq solution. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 Clenpiq solution.  
 
Benefits for these services 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion supplies (A4221, J1559, and K0552) 
provided on April 23, 2020. 
 
You asked the Plan to pay for the home infusion supplies. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says they were unable to make a determination 
within the allotted time frame. 
 
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 a valid proof of delivery for the supplies provided in this case. 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 home infusion supplies (A4221, J1559, and K0552) provided 
on April 23, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 3, 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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on December 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraspinal chiropractic manipulative treatment (code 
98943) and the electrical stimulation (code G0283) provided by a chiropractor on December 1, 2021. 
 
You asked the Plan to pay for the chiropractic services.. You say that these services were medically necessary. 
The Plan denied your request. The Plan says these are not Medicare-covered chiropractic services.  While the 
member does have a supplemental chiropractic benefit for non-Medicare covered chiropractic services, the 
member has exhausted that benefit for 2021. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. The Plan does have a 
supplemental chiropractic benefit that will cover chiropractic services beyond manual manipulation of the spine.  This benefit is limited to 30 visits each calendar year.  Records show that the member exhausted this 30-
visit maximum, so no additional non-Medicare covered chiropractic services are eligible for coverage after that 
date. Therefore, we decided that the Plan does not have to pay for the extraspinal chiropractic manipulative 
treatment (code 98943) and the electrical stimulation (code G0283) provided by a chiropractor on December 1, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the osteogenesis stimulator (code E0748) billed for date of 
service October 17, 2021. 
 
You asked the Plan to pay for the osteogenesis stimulator. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says you did not bill with the appropriate modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that devices coded E0748 are classified by the Food 
and Drug Administration as Class III devices; therefore, all claims for code E0748 must include the KF 
modifier. Claim lines billed without a KF modifier will be rejected as missing information.  Records show that 
you did not bill this item with the required KF modifier. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the osteogenesis stimulator have not been met. Therefore, we decided that the Plan does not have 
to pay for the osteogenesis stimulator (code E0748) billed for date of service October 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (LSO) rendered on September 20, 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating 
physician before dispensing any durable medical equipment (DME) item to a beneficiary. 
 
We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 lumbar-sacral orthosis (LSO) rendered on September 20, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 3, 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 lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on August 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services (22310) provided on September 15, 
2021. 
 You asked the Plan to pay for code 22310. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 22310 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of code 
22310 have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services 
(22310) provided on September 15, 2021.