Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on March 30, 
2023. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that this should have been a screening 
procedure, you have been trying to get this taken care of for a long time. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment for in-network ambulatory surgical services. 
 
You have been asked to pay a $300 copayment for a colonoscopy. This item/service falls within the in-network 
ambulatory surgical 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 a 
colonoscopy provided on March 30, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow harvesting (38232). 
 
You asked the Plan to pre-approve bone marrow harvesting. You say that the requested service is a necessity 
for your care. The Plan denied your request. The Plan says the requested service is 
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 bone marrow harvesting. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that bone marrow aspirate is experimental. More research is needed to demonstrate its safety 
and efficacy. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow harvesting have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow harvesting (38232).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on July 
15, 2023. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you responsibility should 
be $160 and not $250. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for ambulance services. 
 
You have been asked to pay a $250 copayment for the ambulance services. This item/service 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 the ambulance 
services provided on July 15, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care on 
March 1, 2022, to April 1, 2022.  
 
You asked the Plan to waive the copayment for the skilled nursing facility (SNF) care. You say that the 
member was not able to care for herself once she was wheelchair bound and other health complications. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $0 copayment per day, days 1-20 and a $161 copayment per day, days 21-100 at a skilled nursing 
facility. You were admitted on 2/10/22 - 2/28/22 and then readmitted on 3/1/22. For the service it's 30 x $161 = 
$4,830. Therefore, results in the total cost sharing amount of $4,830. The enrollee has been asked to pay a $161 copayment per day for the skilled nursing facility (SNF) care. This 
item/service falls within the skilled nursing facility (SNF) care benefit category. This means that the enrollee 
has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for the skilled nursing facility (SNF) care on March 1, 2022, to April 1, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
September 3, 2023. 
 
You asked the Plan to pay for the ED services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment. The service was provided after the Public Health Emergency and there is no 
documentation that the Ambulatory Surgery Center was approved as a Freestanding Emergency Department. 
Therefore, we decided that the Plan does not have to pay for the emergency department (ED) services provided 
on September 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing (88341, 88342, 88360, 88381) provided 
on July 27, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the genetic testing. You say that you disagree with this determination and request 
a redetermination of the denial.  The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the genetic testing (88341, 88342, 88360, 88381) 
provided on July 27, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the laboratory services provided on July 
10, 2023. 
 
You asked the Plan to waive the coinsurance for the laboratory services. You say that you have not received a 
bill for this service in the past. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 40% 
coinsurance for out-of-network outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay 40% coinsurance for the laboratory services. This item/service falls within the out-of-network outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for the laboratory services provided on July 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the miscellaneous surgical supply, vaginal dilator 
(A4649). 
 
You asked the Plan to pre-approve the vaginal dilator. You say that you need to use this in conjunction with 
pelvic floor therapy, that is a covered benefit. The Plan denied your request. The Plan says this item is not 
covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the miscellaneous surgical supply, vaginal dilator (A4649).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 10, 2023. 
 
You asked the Plan to pay for the lab services. You say that this should be paid for. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 provided on July 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oncology (melanoma), gene expression profiling (0089U) 
provided on August 29, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the genetic testing. You say that based on the supporting documentation that 
clearly shows medical necessity per Medicare criteria, you request for overturn of the denial and reprocess the 
claim.  The Plan denied your request. The Plan says enrollees must receive their medical services from an in-
network provider with the exception being urgent or emergent services. Non-emergent services with non-
contracted providers require prior authorization before services being rendered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the oncology (melanoma), gene expression 
profiling (0089U) provided on August 29, 2023, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a single-photon emission computerized tomography 
(SPECT) scan. 
 
You asked the Plan to pre-approve a SPECT scan. You say that this test is needed to check for a broken bone or 
infection when magnetic resonance imaging (MRI) cannot be done. You say the patient's past MRI's have been 
non-diagnostic for his symptoms, as they show no spinal canal stenosis and the patient has exhausted 
conservative therapy without relief so a SPECT scan is needed to guide future injections and surgery. The Plan 
denied your request. The Plan says a SPECT scan is intended to be used when other imaging studies are non-
diagnostic or when other imaging procedures provide equivocal or inconclusive results. 
 
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 SPECT scan. Our reviewer says that the requested SPECT scan is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the last conventional imaging including MRI was done in 2016.  The neurological exam is 
negative. The medical necessity of requested SPECT scan has not been established in the submitted records. 
 
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 SPECT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a SPECT scan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient for a home or residence visit (99348) 
provided on June 13, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the home or residence visit . You say that please review the attached documents 
and reprocess the claim. The Plan denied your request. The Plan says enrollees must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the established patient for a home or residence 
visit (99348) provided on June 13, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for otolaryngology services (69200, 99213) provided on May 5, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the otolaryngology services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the service was 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 otolaryngology services (69200, 99213) provided on May 5, 2023, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the acupuncture visits provided on March 
14, 2023, to April 8, 2023. 
 
You asked the Plan to waive the copayment for the acupuncture visits. You say that you were told you could go 
to an out-of-network provider and the coverage would be the same as if you were to see an in-network 
provider. The Plan denied your request. The Plan says the provider has opted out of the Medicare program and 
therefore cannot bill for non-emergent service. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. The provider opt out effective date is April 1, 2022. Therefore, we 
decided that the Plan does not have to waive the copayment for the acupuncture visits provided on March 14, 
2023, to April 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat radiofrequency ablation (RFA) of the lumbar 
spine. 
 
 
 You asked the Plan to pre-approve repeat radiofrequency ablation. You say that you are requesting 
reconsideration for the denial of the RFA. The Plan denied your request. The Plan says the records do not show 
the previous response to lumbar radiofrequency ablation, including documentation of at least 50% 
improvement in the enrollee's pain. 
 
The Plan follows Medicare rules. Medicare rules say that repeat RFA at the same anatomic site is considered 
medically reasonable and necessary provided the patient had a minimum of consistent 50% improvement in 
pain for at least 6 months. 
 
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 repeat radiofrequency ablation. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found there is no 
documentation of the degree and duration of the pain relief achieved. Therefore, the request is deemed not 
medically reasonable and 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 repeat radiofrequency ablation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve repeat radiofrequency ablation (RFA) of the lumbar spine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a hospital bed. You say that the partial electric be that was delivered is not 
helpful to you. The Plan denied your request. The Plan says total electric hospital beds are not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Doxepin HCL tablets (J8499). 
 
You asked the Plan to pre-approve the medication. You say that this medication is medically necessary and 
appropriate. The Plan denied your request. The Plan says the medication is not covered as a medical benefit 
under the Plan. 
 
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 Doxepin HCL tablets 
(J8499).  
 
Benefits for the medication 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73610 provided on September 3, 2023. 
 
You asked the Plan to pay for procedure code 73610. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
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 73610 is not supported in the medical record. Specifically, code 73610 has a status 
indicator of Q1 and was billed on the same date of service as code 99283 which has a status of "V". Code 
73610 is a packaged service in this case and is not separately payable. Based on this information, we decided 
that Medicare rules for coverage of procedure code 73610 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 73610 provided on September 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4239 provided on July 17, 2023. 
 
You asked the Plan to pay for procedure code A4239. 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. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee has not had an in-
person visit with their treating physician to evaluate their diabetes control and to determine whether the criteria 
for coverage have been met.  Based on this information, we decided that Medicare rules for coverage of 
procedure code A4239 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code A4239 provided on July 17, 2023.