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

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically reasonable 
and necessary. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental. More research is needed before coverage can be 
approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the EEG (95718) provided on February 11, 2022. 
 
You asked the Plan to pay for the EEG (95718). You say that a second test was done and modifier 59 was 
added to show that two separate tests were performed. You say that the physicians provided medically 
necessary services to the member in good faith and the attached notes should be reconsidered for payment. The 
Plan denied your request. The Plan says that per code edits, bundled services with an indicator of 0 are not 
payable. 
 
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. The Plan says CPT code 95718 is a bundled service with an indicator of 0 and 
cannot be separately paid. The Plan did not submit documentation showing another service was billed on this 
date for CPT code 95718 to be considered an inclusive column II code and not separately payable. Therefore, 
we decided that the Plan has to pay for the EEG (95718) provided on February 11, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (85060) provided January 21, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim was not billed with a valid place of service. 
 
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 code 85060 is not supported in the medical record. Specifically, the claim has a PC/TC 
indicator of 8. Payment for this service is made to the hospital when the patient is receiving the service as a 
hospital patient. This service is not eligible for separate payment. 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 (85060) provided January 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires 
a trial of Infed and Venofer before it will approve Injectafer. 
 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 Injectafer. Our reviewer says that the 
enrollee does not meet the Medicare criteria for a step therapy exception for Injectafer. Our physician reviewer 
found the enrollee has not tried and failed the Plan's preferred drugs of Infed and Venofer. The record does not 
show that these drugs would likely be less effective and/or 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Injectafer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for acupuncture services provided from May 
10, 2021, to July 21, 2021. 
 
You asked the Plan to waive the deductible for the acupuncture services. You say that you should be covered 
for up to 12 visits. The Plan denied your request. The Plan says the correct amount was applied to your 
deductible. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $1,000 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Acupuncture for Chronic 
Low Back Pain benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract 
that there is $1,000 deductible which applies to certain items and services. This cost sharing is a contractual 
obligation that had not been met at the time the acupuncture services were received on May 10, 2021, to July 
21, 2021. Therefore, we decided that the Plan does not have to waive the deductible for acupuncture services 
provided from May 10, 2021, to July 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 18, 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 February 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplicate claim for laboratory services (88305 and 
88112) provided on October 22, 2021. 
 
You asked the Plan to pay for codes 88305 and 88112. 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 supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the laboratory services (88305 and 
88112) provided on October 22, 2021, have been met. In this case, there were no medical records provided 
confirming that two separate laboratory services with codes 88305 and 88112 were provided on October 22, 
2021. The file shows that the Plan paid for one claim with codes 88305 and 88112 provided on October 22, 
2021. Therefore, we decided that the Plan does not have to pay for the duplicate claim for laboratory services 
(88305 and 88112) provided on October 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has failed multiple times at a 
lower level of care. This enrollee will benefit from LTAC services vs SNF. The Plan denied your request. The 
Plan says rules for LTACH care have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where she is 
currently receiving care. In addition, the Plan would not be responsible for services through the end of the 
month since the enrollee is under the hospice benefit. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided on December 6, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were not emergent or pre-authorized. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided 
that the Plan does not have to pay for lab services (G0483) provided on December 6, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
February 21, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you were not given 
a choice to be transported by your son. You say the ambulance only gave you a COVID-19 test. 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 each one-way ambulance trip.  
 
You have been asked to pay $238.54, which is less than the $250 copayment for the ambulance transportation. 
The ambulance transportation 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 transportation provided on February 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you would like additional rides for 
your appointments. The Plan denied your request. The Plan says your benefit limit has been met. The Plan also 
says that there is not an exception that would allow the Plan to cover more than the 24 one-way rides to 
approved locations. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 24 one-way trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency taxi transportation (A0100). 
 
You asked the Plan to pre-approve additional transportation. You say that you would like to appeal the non-
emergent transportation for dialysis. The Plan denied your request. The Plan says you have exhausted the 
established benefit of 24 one-way trips. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to twenty-four (24) (one way) trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency taxi transportation (A0100).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from October 23, 2020, 
to October 31, 2020, at the Diagnosis Related Group (DRG) billed 
 You asked the Plan to pay for the inpatient services at the DRG billed. You say that this was an appropriate 
diagnosis for the patient's stay. The Plan denied your request. The Plan says the secondary diagnosis of E43 
(unspecified severe protein calorie malnutrition) is not supported in the medical record, so the DRG billed was 
not correct. 
 
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 secondary diagnosis of E43 (unspecified severe 
protein calorie malnutrition). 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 
services at the DRG billed. Our reviewer says that the secondary diagnosis of E43 (unspecified severe protein 
calorie malnutrition) is not supported in the medical record Our physician reviewer found the patient is an 82-
year old female who has spondylolisthesis of the lumbar spine. The patient was noted to be well-developed, 
with a decreased dietary intake at <25% of normal for one week due to lack of appetite and nausea and 
experienced approximately a 5 lbs weight loss (3%) in the past week. Her body mass index (BMI) was 23.9. 
The secondary diagnosis of E43 (unspecified severe protein calorie malnutrition) was not supported in the 
medical record based on the fact that the duration of low dietary intake was short (less than 2 weeks), her 
weight loss was minimal (<10%), and physical findings did not show evidence of muscle wasting and BMI was 
above 20.  
 
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 from October 23, 2020, to October 31, 2020, at the Diagnosis Related 
Group (DRG) billed
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the refraction provided on February 10, 2022.
You asked the Plan to pay for the refraction. You say that this bill was sent to the wrong vendor, and you are not responsible for this. The Plan denied your request. The Plan says eye refractions are only covered if performed by a participating provider and performed as a routine screening.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan only covers a refraction when received during a routine exam with a participating vision care provider. 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the refraction have not been met. Specifically, the refraction was not performed with a routine eye exam. Therefore, we decided that the Plan does not have to pay for the refraction provided on February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refractions (92015) provided on December 20, 2021.
You asked the Plan to pay for the eye refractions. You say that you were told this charge should be covered. The Plan denied your request. The Plan says eye refractions are only covered by your plan if performed by a participating Plan approved provider and performed as a routine screening. The Plan also says that this service is not a covered benefit because it was performed with a medical diagnosis (Age-related nuclear cataract, bilateral).
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers eye refractions during a routine exam when performed by a Plan approved routine vision care provider. 
We looked at the file and the Plan's rules. Specifically, the eye refractions are not covered since it was performed with a medical diagnosis of Age-related nuclear cataract, bilateral. Based on this information, we decided that the Plan's rules for coverage of the eye refractions have not been met. Therefore, we decided that the Plan does not have to pay for the eye refractions (92015) provided on December 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on February 10, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that this is a false claim. The Plan denied 
your request. The Plan says self-administered drugs are not a covered benefit while under an outpatient hospital 
stay. 
 
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 pay for the self-administered drugs 
provided on February 10, 2020.  
 Benefits for self-administered drugs 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Screening mammography (77067) and screening 
tomosynthesis (77063), provided on December 2, 2021. 
 
You asked the Plan to pay for the Screening mammography and screening tomosynthesis. You say that the 
service should be covered. The Plan denied your request. The Plan says you already received this service on 
March 18, 2021. 
 
The Plan must follow Medicare rules. Medicare rules say that the Plan must cover what Medicare covers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Screening mammography and screening tomosynthesis have not been met. Specifically, you 
have have exhausted the allowed amount for this service per a year. Therefore, we decided that the Plan does 
not have to pay for the Screening mammography (77067) and screening tomosynthesis (77063), provided on 
December 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an automatic blood pressure machine (A4670), provided on 
February 9, 2022. 
 
You asked the Plan to pay for an automatic blood pressure machine. You say that the item is medically 
necessary. The Plan denied your request. The Plan says you obtained this item through a supplier that is not 
enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for an automatic blood pressure machine 
(A4670), provided on February 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specialist visit, provided on February 14, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the specialist visit. You say that the service should be covered. The Plan denied 
your request. The Plan says you obtained this service through an out-of-network provider. 
 
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 the specialist visit, provided on February 14, 2022 
by an out-of-network (OON) provider.