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

We decided that the Plan does not have to waive the copayments for specialist office visits (99213, 99214) provided from May 26, 2021, to June 28, 2021. We also decided that the Plan does not have to waive the coinsurance for a dexamethasone sodium phosphate injection (J1100) provided on May 26, 2021.
You asked the Plan to waive the copayment for specialist office visits. You also asked the Plan to waive the coinsurance for a dexamethasone sodium phosphate injection. 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 $35 copayment for physician specialist services. Your contract with the Plan also clearly says that you must pay a 20% coinsurance for Medicare Part B Prescription Drugs. You have been asked to pay a $35 copayment for two specialist office visits for a total of $70 ($35 copayment x 2 office visits = $70). You also have been asked to pay $.03 in coinsurance, which is 20% of the allowed amount for a dexamethasone sodium phosphate injection ($.16 allowed amount x 20% coinsurance = $.03). Dexamethasone sodium phosphate injections fall within the Medicare Part B Drug 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 copayments for specialist office visits (99213, 99214) provided from May 26, 2021, to June 28, 2021. We have also decided that the Plan does not have to waive the coinsurance for a dexamethasone sodium phosphate injection (J1100) rendered on May 26, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six (6) home health physical therapy visits. 
 
You asked the Plan to pre-approve the services. You say that the home health physical therapy visits are 
medically necessary based on unsteadiness on feet. The Plan denied your request. The Plan says the services 
are not necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 services. Our physician reviewer 
found the documentation does not support that the enrollee requires additional skilled rehabilitation services to 
provide treatment that is medically necessary. The enrollee does not require additional skilled rehab services to 
effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a 
maintenance program to maintain the enrollee's condition and/or prevent deterioration. The enrollee has been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The 
requested home health services are not 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 pre-approve six (6) home health physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse for the office visit (CPT code 99202) provided on March 30, 2021, by an out-of-network provider.
You asked the Plan to reimburse for the office visit. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were 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 reimbursement 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 reimbursement for these items/services. Therefore, we decided that the Plan does not have to reimburse for the office visit (CPT code 99202) provided on March 30, 2021, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain 
rendered on June 15, 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 are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography 
angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with 
column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. 
Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the 
head/brain rendered on June 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Computed Tomography (CT) scan of the 
abdomen provided by an in-network outpatient hospital facility on June 2, 2021. 
 
You asked the Plan to waive the copayment for a CT scan of the abdomen. You say that the services should 
have been covered under the $90 payment you made on May 19, 2021, for Emergency Room (ER) services that 
were relative to the issue. You state you were not told you would have to pay an additional charge for the CT 
scan and feel this is a double charge. The Plan denied your request. The Plan says the cost-share for the 
imaging service was applied correctly. Review of claim history indicated no ER claim on file as well as no ER 
service billed on the claim at issue. 

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 Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
You have been asked to pay a $171.04 copayment for a CT scan of the abdomen. CT scans fall within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The allowed amount the 
Plan has approved for payment is less than the required $250 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 a Computed Tomography (CT) scan of the abdomen provided by an in-network outpatient 
hospital facility on June 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the debridement of subcutaneous tissue 
(11042) and for the application of multi-layer compression system (29581) provided from February 2, 2021, to 
February 23, 2021. 
 
You asked the Plan to waive the copayments for the debridement of subcutaneous tissue and for the application 
of multi-layer compression system. You say that you do not feel that you should be responsible for the billed 
amount. 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 $295 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges.  
 
You have been asked to pay a $295 copayment for 3 visits of the debridement of subcutaneous tissue and for 
the application of multi-layer compression system for a total of $885 ($295 x 3 = $885). You also have been 
asked to pay $140.42, which is less than the $295 copayment, for 3 visits of the application of multi-layer 
compression system for a total of $421.26 ($140.42 x 3 = $421.26). The debridement of subcutaneous tissue 
and the application of multi-layer compression system fall within the 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 copayments for the 
debridement of subcutaneous tissue (11042) and for the application of multi-layer compression system (29581) 
provided from February 2, 2021, to February 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON)
provider.
You asked the Plan to pre-approve office visits to be provided by an OON provider. You say that the services
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to
provide these services. Therefore, coverage criteria have not been met.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
office visits to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on January 5, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were
billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 the drug testing services provided on January 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a TENS device and supplies, intermittent limb compression 
devices, and compounded multivitamin injections provided on December 14, 2020. 
 
You asked the Plan to pay for a TENS device and supplies, intermittent limb compression devices, and 
compounded multivitamin injections. You say that the requested items/services were a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan follows Medicare rules. The rules state that Medicare will cover a TENS device and supplies when 
the enrollee is enrolled in an approved clinical study. The rules say that Medicare covers pneumatic devices 
when medically necessary for the treatment of lymphedema and/or for the treatment of chronic venous 
insufficiency with venous stasis ulcers. The rules also say that claims for compounded drugs shall be submitted 
using a compounded drug, NOC code. 
 
The file does not show that the enrollee is enrolled in an approved clinical study; or that the enrollee has 
lymphedema and/ or chronic venous insufficiency with venous stasis ulcers. The rules require that any 
compounded drug be billed using a NOC code. As the compounded drug at issue was not billed properly, 
payment cannot be made. Therefore, we decided that the Plan does not have to pay for a TENS device and 
supplies, intermittent limb compression devices, and compounded multivitamin injections provided on 
December 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intermittent limb compression devices (E0673, E0675) provided on May 18, 2021.
You asked the Plan to pay for intermittent limb compression devices. You say that the items at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for prevention of deep vein thrombosis.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers.
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous
stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression
devices (E0673, E0675) provided on May 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the colon x-ray rendered on December 29, 2020.
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 only one unit is supported.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be
exact duplicates of another claim or claim line are denied.
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the
Plan on a separate claim for the same date of service. The documentation supports payment of only one unit of
the services. 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 colon x-ray rendered on December
29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the foot insert (CPT code L3020)
You asked the Plan to pre-approve the foot insert. You say that you have high arches, hammer toes and a neuroma in your foot. The Plan denied your request. The Plan says you do not have a qualifying condition for shoe inserts. The Plan states you are not diabetic and the shoe/orthotic is not an integral part of a brace or prosthetic. Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve the foot insert (CPT code L3020)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 panel (CPT code(s): 81120, 81121, 81173, 
81201, 81210, 81235, 81270, 81272, 81275, 81276, 81293, 81299, 81301, 81308, 81309, 81310, 81311, 81314, 
81321, 81400, 81401, 81401-59, 81402, 81403, 81403-59, 81404, 81404-59, 81405, 81405-59, 81406, and 
81406-59) provided to the enrollee on May 18, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the enrollee meets the medical necessity criteria for the requested panel to be 
performed. The Plan states the rules say that the Guardant360 panel must be billed with procedure code 81479 
and the file shows that the Guardant360 panel was not billed with code 81479, but as a panel of codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The rules say that the Guardant360 panel must be billed with procedure code 81479 and the file shows that the 
Guardant360 panel was not billed with code 81479, but as a panel of codes. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided 
that the Plan does not have to pay for Guardant360 panel (CPT code(s): 81120, 81121, 81173, 81201, 81210, 
81235, 81270, 81272, 81275, 81276, 81293, 81299, 81301, 81308, 81309, 81310, 81311, 81314, 81321, 81400, 
81401, 81401-59, 81402, 81403, 81403-59, 81404, 81404-59, 81405, 81405-59, 81406, and 81406-59) 
provided to the enrollee on May 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MyoPro 2 Motion G orthotic device. 
 
You asked the Plan to pre-approve upper extremity orthosis. You say that this device cannot be considered 
experimental/investigational and meets the enrollee's medical needs. The Plan denied your request. The Plan 
says the denial of authorization for this device is correct, because studies have not proven that this device is 
helpful for the enrollee. 
 
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 upper extremity orthosis. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient literature in the peer-reviewed publications to assess the safety, 
efficacy, long-term outcomes, or patient management associated with use of the MyoPro orthosis for upper 
extremity paralysis/paresis from conditions such as the enrollee's.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of upper extremity orthosis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve MyoPro 2 Motion G orthotic device.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy (CPT code 45380) 
provided on May 14, 2021. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that you are appealing your cost-
share responsibility for the services you received. The Plan denied your request. The Plan says the claim was 
processed accordingly with your 2021 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received a colonoscopy at an ambulatory surgical center. You were asked to 
pay a $200 copayment for the colonoscopy. Your 2021 EOC states that enrollees must pay a $200 copayment 
per visit at ambulatory surgical centers. 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 
colonoscopy (CPT code 45380) provided on May 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for evaluation of oral and pharyngeal swallowing function (CPT 
code 92610) provided to the enrollee on June 26, 2020. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Current Procedural Terminology (CPT) code 92610-GN-KX (1 unit) remains not supported. The submitted 
medical records indicate that speech therapy service was performed in the home setting. The Current 
Procedural Terminology (CPT) code 92610 is not an appropriate code to bill speech therapy discharge service 
in the home setting. Of note there is a more appropriate Healthcare Common Procedure Coding System 
(HCPCS) code (G0153) for services performed by a qualified speech-language pathologist in the home health 
or hospice setting; therefore, the billed service cannot be verified. It is noted that multiple attempts were made 
to contact the provider for additional information. Based on this information, we decided that Medicare rules 
for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pay for 
evaluation of oral and pharyngeal swallowing function (CPT code 92610) provided to the enrollee on June 26, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intermittent limb compression devices (E0673, E0675) 
provided on March 19, 2021. 
 
You asked the Plan to pay for intermittent limb compression devices. You say that the items at issue are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says pneumatic compression devices 
are not covered by Medicare for prevention of deep vein thrombosis. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression 
devices (E0673, E0675) provided on March 19, 2021.