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

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
September 16, 2023. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that the cost share is 
wrong. 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 $110 
copayment for emergency care. 
 
You have been asked to pay a $110 copayment for the emergency room services. This item/service falls 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 the emergency room 
services provided on September 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64611 and J0588 provided on May 11, 
2023. 
 
You asked the Plan to pay for procedure codes 64611 and J0588. You say that the medical records support the 
billing of procedure codes 64611 and J0588. The Plan denied your request. The Plan says the medical records 
do not support the billing of procedure codes 64611 and J0588. 
 
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 64611 is Chemodenervation of parotid and 
submandibular salivary glands, bilateral. The definition of code J0588 is Injection, incobotulinumtoxin a, 1 
unit. 
 
We asked our coder 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 procedure codes 64611 and J0588. Our reviewer says that the 
medical records do not support the billing of procedure codes 64611 and J0588. Our reviewer found the 
medical records provided do not include sufficient documentation to validate that a Chemodenervation of 
parotid and submandibular salivary glands, bilateral was performed on May 11, 2023, therefore this procedure 
cannot be verified. Additionally, the medical records provided do not include sufficient documentation to 
validate that an Injection, incobotulinumtoxin a, 1 unit was performed on May 11, 2023, therefore this 
procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 64611 and J0588 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 64611 and J0588 provided on May 11, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Promethazine tablets. 
 
You asked the Plan to pre-approve the medication. 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 Promethazine tablets.   
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the injection (J7327) provided on August 
16, 2023. 
 
You asked the Plan to waive the coinsurance for the injection (J7327). You say that the cost share is wrong. 
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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for the injection (J7327). This item/service falls within the 
Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for 
the injection (J7327) provided on August 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for four units of tracheostomy/laryngectomy tube, non-cuffed, 
polyvinylchloride (pvc), silicone or equal, each (A7520) provided on May 9, 2023. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says excess supplies are denied as not reasonable and necessary. 
 
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 that the request is for 4 non-cuffed tracheostomy tubes. This was denied because it exceeds the 
maximum number allowed, which is 1 every 3 months. The enrollee is 24 years old, and has congenital 
myopathy, with ventilator dependence since birth. The medical records do not document any increased need for 
replacement tracheostomy tubes. 1 item every 3 months should be sufficient to meet this enrollee's needs. 
 
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 four units of tracheostomy/laryngectomy tube, non-cuffed, polyvinylchloride (pvc), silicone or 
equal, each (A7520) provided on May 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit. provided on July 12, 2023. 
 
You asked the Plan to pay for an office visit.. You say that you have previously seen this provider without 
issue. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that 
would require the Plan to pay for the item(s)/service(s). You also say you did not know you were not certified to go there and that the provider's office said your insurance should pay for  it. Therefore, we decided that the 
Plan does not have to pay for an office visit. provided on July 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) on June 27, 2023. 
 
You asked the Plan to pay for a continuous glucose monitor (CGM). You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the documentation requirements 
have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery which support medical necessity for the supplies provided 
in this case. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor 
(CGM) on June 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total disc arthroplasty. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this does not meet the requirements for approval. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the the provider is requesting this procedure at C4-5 and C6-7. The use of total disc arthroplasty is 
not supported at 2 levels when those 2 levels are not contiguous. There are limited large-scale, long-term 
references showing the safety and efficacy of the requested surgery in this clinical setting. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested total disc arthroplasty at C4-5 and C6-7 is not medically 
reasonable or 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 total disc arthroplasty.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Tempus xR Solid Tumor testing (81456) provided on July 25, 2023. 
 
You asked the Plan to pay for Tempus xR Solid Tumor testing. You say that this test was medically necessary 
and appropriate. The Plan denied your request. The Plan says that this test is not medically necessary as it does 
not have the appropriate FDA approval. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 Tempus xR Solid Tumor testing. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found that the Tempus xR Solid Tumor testing assay utilizes tumor-normal matched 
samples for highly accurate somatic alteration calling and whole transcriptome ribonucleic acid (RNA) 
sequencing for unbiased identification of gene fusion events. The assay was validated with a combination of 
clinical specimens and cell lines, and recorded a sensitivity of 99.1% for single nucleotide variants, 98.1% for 
indels, 99.9% for gene rearrangements, 98.4% for copy number variations, and 99.9% for microsatellite 
instability detection. This assay presents a wide array of data for clinical management and clinical trial 
enrollment while conserving limited tissue. The review has determined that the items/services at issue in this 
case are medically reasonable and necessary. All of the criteria from the National Coverage Determination are 
met. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tempus xR Solid Tumor testing have been met. Therefore, we decided that the 
Plan has to pay for Tempus xR Solid Tumor testing (81456) provided on July 25, 2023.  
 
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 laboratory services (procedure code 87640-59) rendered on 
June 6, 2023. 
 
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 Current Procedural Terminology (CPT) code 87640-59 (1 Unit) remains not supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 that the 
medical record does not include documentation to support rationale of separate billing. CPT code 87641 was 
established to report methicillin resistant Staphylococcus aureus (MRSA) by amplified probe technique and it is used to bill for assays that detect methicillin resistance and identify Staphylococcus aureus using a single 
nucleic acid sequence. In this case, the service was incorrectly unbundled. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services (procedure code 87640-59) rendered on June 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the treatment of bladder lesion provided on 
September 08, 2023. 
 
You asked the Plan to reduce the copayment for the treatment of bladder lesion. You say that you believe this 
was billed incorrectly and you should only have a copayment of $13.08. 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 $335 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
You have been asked to pay a $335 copayment for the treatment of bladder lesion. This item/service falls 
within the outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for the 
treatment of bladder lesion provided on September 08, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to increase the reimbursement for the ambulance service, an x-ray, the 
inpatient hospital stay, and the dormitory service provided from February 6, 2023, to March 14, 2023. 
 
You asked the Plan to increase the reimbursement for the ambulance service, an x-ray, the inpatient hospital 
stay and the dormitory service. You say that you were reimbursed the incorrect amount. The Plan denied your 
request. The Plan says you were reimbursed the correct 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 $290 
copayment per date of service, regardless of the number of trips for in-network ambulance services. Your 
contract with the Plan also clearly says that you must pay a $70 copayment for in-network diagnostic 
procedures and tests. Your contract with the Plan also clearly says that you must pay a $250 copayment per 
day, for days one to six and a $0 copayment per day, for days seven to ninety for in-network inpatient care. 
 
 
 
 
 You have been asked to pay $6.04, which is less than the standard copayment for the ambulance service 
provided on February 17, 2023. This item/service falls within the ambulance services benefit category. You 
have also been asked to pay $31.61, which is less than the standard copayment for the x-ray provided on March 
14, 2023. This item/service falls within the outpatient diagnostic tests and therapeutic services and supplies 
benefit category. You have also been asked to pay $982.44, which is less than the standard copayment for the 
inpatient hospital stay provided from February 6, 2023, to February 17, 2023. This item/service falls within the 
inpatient hospital care benefit category.  
 
You have also been asked to pay $638.45 for the dormitory services. These services were not an urgent or 
emergent medical issue therefore, these services are not covered. The record shows you should only be 
reimbursed $5,374.53, which is the maximum allowable amount. This means that you have been reimbursed 
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 increase the 
reimbursement for the ambulance service, an x-ray, the inpatient hospital stay, and the dormitory service 
provided from February 6, 2023, to March 14, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Actemra. 
 You asked the Plan to pre-approve Actemra. You say that you are requesting reconsideration for the denial of 
Actemra. The Plan denied your request. The Plan says step therapy requirements have 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 Actemra. Our reviewer says that the 
criteria for coverage of Actemra have not been met. Our physician reviewer found the Plan requires a trial of 
Entyvio or Simponi Aria before they will approve the requested drug. In this case, the enrollee has not tried and 
failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) 
would likely be less effective 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 Actemra have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Actemra.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99214) provided on August 
31, 2023. 
 
You asked the Plan to waive the copayment for the office visit (99214). You say that the cost share is wrong. 
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 $10 
copayment for Physician/Practitioner services, including doctors officevisits. 
 
You have been asked to pay a $10 copayment for the office visit (99214). This item/service falls within the 
Physician/Practitioner services, including doctors officevisits 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 office visit (99214) provided on August 31, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the breast imaging services provided on 
July 20, 2023. 
 
You asked the Plan to waive the copayment for the breast imaging services. You say that you should not have 
been charged on cost share on these claims. 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 $150 
copayment for in-network diagnostic procedures and tests provided in an outpatient hospital setting.  
 
 You have been asked to pay a total of $94.85 for the facilities charges for the breast imaging services ($40.47 + 
$11.11 + $43.27 = $94.85). You have also been asked to pay $16.11 for the providers charges for the breast 
imaging services. The total amount you have been asked to pay is less than the standard copayment for these 
services. Breast imaging services fall within the outpatient diagnostic tests and therapeutic 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 breast imaging services provided on July 
20, 2023.