Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Evenity. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no indication that the plan's required drug(s) would likely be less effective and/or likely 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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual gynecological examination provided on  
October 22, 2021. 
 You asked the Plan to pay for an annual gynecological examination. You say that this is a provider billing 
error. The Plan denied your request. The Plan says your account shows a routine GYN exam was provided on 
June 21, 2021. 
 
The Plan contract says the Plan covers cervical and vaginal cancer screening. For all women: Pap tests and 
pelvic exams are covered once every 24 months. 
 
We looked at the file and Medicare rules. The file shows you received the benefit for an annual gynecological 
examination on June 21, 2021. Based on this information, we decided that Medicare rules for coverage of an 
annual gynecological examination have not been met. Therefore, we decided that the Plan does not have to pay 
for an annual gynecological examination provided on October 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (83520, 83631, 82656, 87338, 87150) provided 
January 12, 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 documentation does not support the billed services. 
 
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 lab 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 lab services (83520, 83631, 82656, 87338, 87150) provided January 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from May 
3, 2021, to May 5, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this was submitted with the incorrect DRG.  
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 DRG 707. 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 services at issue in this case were not 
supported by the medical records. Our physician reviewer found the review has determined that DRG 707: 
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC is not appropriate. DRG 708: MAJOR MALE 
PELVIC PROCEDURES WITHOUT CC/MCC is the appropriate DRG for this case. He underwent the 
procedure without reported complications and per report had an estimated blood loss of 450 cc. There was no 
documentation of unexpected bleeding, and the patient was noted to have routine post operative laboratory 
studies. He was discharged from the hospital with a hematocrit (HCT) of 37. He received no intervention for 
the HCT prior to discharge.  
 
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 to the enrollee from May 3, 2021, to May 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supplies provided to the enrollee on November 23, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says no separate payment can be made. 
 
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 99072 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99072 is not separately payable. 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 supplies 
provided to the enrollee on November 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthoses provided to the enrollee on February 18, 2021. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation did not include a valid physician order. 
 
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 the provided records do not document knee instability on examination of the enrollee with objective 
description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test). Additionally, it was 
confirmed that the "ordering provider" did not actually order the denied items. The enrollee has confirmed that 
they contacted directly by the durable medical equipment (DME) company. Given this information and review 
of the records provided, there does not appear to be a valid order for the brace. 
 
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 orthoses provided to the enrollee on February 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99100) provided October 22, 2021. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the billed code is 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 CPT code. 
 
We find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for 
physician services (99100) provided October 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87486, 87496, 87498, 87541, 87581, 87631, 
87640, 87798) provided September 25, 2020. 
 
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 documentation does not support the billed services. 
 
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 lab 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 lab services (87486, 87496, 87498, 87541, 87581, 87631, 87640, 87798) 
provided September 25, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided 
December 14, 2021 to December 16, 2021. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that the copayment 
should be waived. The Plan denied your request. The Plan says the correct cost-sharing was applied. 
 
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 $90 
copayment for Emergency Care.  
 
You have been asked to pay a $90 copayment for the emergency room services. The emergency room services 
fall within the Emergency Care 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 
emergency room services provided December 14, 2021 to December 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675) provided 
November 17, 2021. 
 
You asked the Plan to pay for the pneumatic compression device. You say that the items were medically 
necessary. The Plan denied your request. The Plan says the code was not billed with a valid place of service. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the pneumatic compression device was used in a SNF or hospital. Therefore, we decided 
that the Plan does not have to pay for a pneumatic compression device (E0673, E0675) provided November 17, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6. 
 
You asked the Plan to pre-approve a Dexcom G6. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 
 
 We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a Dexcom G6 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder Triage test provided on February 4, 2021. 
 
You asked the Plan to pay for the Cxbladder Triage test. The Plan denied your request. The Plan says the 
Cxbladder Triage test is investigational/experimental. 
 
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 Cxbladder Triage test. Our reviewer says 
that the requested the Cxbladder Triage test is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the record indicates that the enrollee underwent the requested test. The 
provided records are insufficient to determine the medical necessity of the requested service. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the 
requested service. The elements of the coverage criteria are not satisfied.   
 
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 Cxbladder Triage test have not been met. Therefore, we decided that the 
Plan does not have to pay for the Cxbladder Triage test provided on February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Transthoracic Echocardiography (TTE). 
 
You asked the Plan to pre-approve a Transthoracic Echocardiography (TTE). You say that the requested TTE is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested TTE. 
 
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 a Transthoracic Echocardiography 
(TTE). Our reviewer says that the enrollee does not meet criteria for the requested TTE. Our physician 
reviewer found at issue is the medical necessity of a repeat TTE, in the absence of any apparent significant 
change in the enrollees clinical condition. Documentation would not point to a change in status that would 
support the medical necessity of a repeat TTE at this time. Clinical guidelines do not support repeating a TTE 
following a relatively recent TTE, with no intervening change in clinical status or new signs, symptoms or 
physical findings. In summary, there is no supportive evidence for the medical necessity of repeat TTE in this 
enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Transthoracic Echocardiography (TTE) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Transthoracic Echocardiography (TTE).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the normal saline solution infusion (J7040) provided on 
October 29, 2021. 
 
You asked the Plan to pay for the normal saline solution infusion (J7040). The Plan denied your request. The 
Plan says code J7040 is packaged under the outpatient prospective payment system (OPPS) and is paid as part 
of the primary procedure that was performed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
  In this case, the CPT Code Manual definition of code J7040 is infusion, normal saline solution, sterile (500 ml 
= 1 unit). 
 
We find that CPT code J7040 is not supported in the medical record. Specifically, CPT code J7040 has a status 
indicator of N. This means that CPT code J7040 is considered packaged and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the normal saline solution infusion (J7040) 
have not been met. Therefore, we decided that the Plan does not have to pay for the normal saline solution 
infusion (J7040) provided on October 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the oxygen concentrator and portable 
oxygen concentrator (DME) provided from October 9, 2021, to February 9, 2022. 
 
You asked the Plan to waive the coinsurance for the oxygen concentrator and portable oxygen concentrator, 
which are considered DME. You say that you are in financial distress and have applied for government 
assistance. The Plan denied your request. The Plan says the coinsurance was applied 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% for 
Medicare-covered equipment and supplies for (DME) and related supplies.  
 
 You have been asked to pay a total of $161.21 for the oxygen concentrator and portable oxygen concentrator.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
October 9, 2021 DME $185.76 20% $37.15 
November 9, 2021 DME $185.76 20% $37.15 
December 9, 2021 DME $143.87 20% $28.77 
January 9, 2022 DME $145.36 20% $29.07 
February 9, 2022 DME $145.36 20% $29.07 
TOTAL:    $161.21 
 
The oxygen concentrator and portable oxygen concentrator falls within the Durable medical equipment 
(DME) and related 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 the oxygen 
concentrator and portable oxygen concentrator (DME) provided from October 9, 2021, to February 9, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic procedure services provided on July 23, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for therapeutic procedure services. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says your request for outpatient physical therapy is denied due 
to the provider's non-participating status, and failure to obtain prior authorization before rendering services. 
 
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 therapeutic procedure services provided on July 
23, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 testing kit provided on January 4, 
2022. 
 
You asked the Plan to pay for the at-home COVID-19 testing kit. 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. 
 
The Plan must follow Medicare rules. CMS says that Plans and insurers are required to cover at-home over the 
counter COVID-19 tests purchased on or after January 15, 2022.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the at-home COVID-19 testing kit have not been met. Specifically, the at-home COVID-19 testing 
kit was purchased before the date of January 15, 2022. Therefore, we decided that the Plan does not have to pay 
for the at-home COVID-19 testing kit provided on January 4, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic procedure services provided on August 2, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for therapeutic procedure services. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says your request for outpatient physical therapy is denied due 
to the provider's non-participating status, and failure to obtain prior authorization before rendering services. 
 
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 therapeutic procedure services provided on August 
2, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Office Visit services provided on November 10, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Office Visit services. You say that you would like to appeal the denial of the 
claim. The Plan denied your request. The Plan says the provider is out-of-network and it was determined these 
services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for Office Visit services provided on November 10, 
2021 by an out-of-network (OON) provider.