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

 
We decided that the Plan does not have to waive the copayment for the biopsy provided on September 07, 
2023. 
 
You asked the Plan to waive the copayment for the biopsy. You say that you disagree with the copayment. 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 $275 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $275 copayment for the biopsy. This item/service falls within the outpatient 
surgery, including services provided at hospital outpatient facilities 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. However, since the allowed amount is less than the 
standard copayment, you only owe $223.44. Therefore, we decided that the Plan does not have to waive the 
copayment for the biopsy provided on September 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and vaccination provided on July 13, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for these services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that their original decision to deny payment was correct. 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 an office visit and vaccination provided on July 
13, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on August 18, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
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 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 
services 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 the services provided on August 18, 2023, by an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator and portable oxygen system to 
be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve an oxygen concentrator and portable oxygen system 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 
an oxygen concentrator and portable oxygen system to be provided 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 scooter battery provided on June 15, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the battery. The Plan denied your request. The Plan says you were told to pay out 
of pocket and you would be reimursed. 
 
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 item at issue in this appeal. The Plan did not pre-approve the item at 
issue. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for the scooter battery provided on June 15, 2023, by an out-of-network (OON) 
provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for infectious-agent testing (87563, 87556, 87640, 87481, 87798) provided 
on April 14, 2023. 
 
You asked the Plan to pay for infectious-agent testing. You say that you have reported the services at issue 
correctly. The Plan denied your request. The Plan says that the services at issue are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's denial indicates that the test at issue is not approved by 
the Food and Drug Administration (FDA). The Plan has not identified the test at issue. We are unable to 
confirm the Plan's denial. It is the Plan's responsibility to support its denial with evidence. In this case, the 
Plan's denial is not supported, so we must find in your favor. Therefore, we decided that the Plan has to pay for 
infectious-agent testing (87563, 87556, 87640, 87481, 87798) provided on April 14, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each enteral formula provided on July 21, 
2023, to August 03, 2023. 
 
You asked the Plan to waive the coinsurance for each enteral formula. You say that the enrollee cannot afford 
the cost share. 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 durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for each enteral formula. This item/service falls within the 
durable medical equipment 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. The amount the enrollee owes for each item is $85.20 ($426 x 
20% = $85.20). The total amount the enrollee owes is $170.40 ($85.20 coinsurance x 2 items = $170.40). 
Therefore, we decided that the Plan does not have to waive the coinsurance for each enteral formula provided 
on July 21, 2023, to August 03, 2023.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure codes 61798 and 61800 rendered on February 15, 
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 the records do not support the services 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 61798: 
 
Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 complex cranial lesion 
 
CPT 61800: 
 
Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for 
primary procedure) 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 61798, the 
records do not support the level of service billed. For CPT 61798, the provider uses externally generated 
ionized radiation to destroy a single, complex cranial lesion in the target area in the brain. The targeted lesion is 
complex, which typically means the lesion is larger than 3.5 cm.  An addendum was also reviewed, when more 
work is performed, a more appropriate modifier should be appended to the appropriate procedure code.  
 
In terms of CPT 61800, this is an add-on service. It can't be approved if the primary procedure has been denied. 
 
We looked at this coder'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 procedure codes 61798 and 61800 rendered on February 15, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio (J3380). 
 You asked the Plan to pre-approve Entyvio. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for Entyvio. 
 
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 Entyvio. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of drug Stelara 
before they will approve the requested drug. In this case, the patient has not tried and failed the required drug. 
Our reviewer also found that there is no documentation provided indicating that the Plans required drug 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 Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio (J3380).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies provided on June 12, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says the services were not 
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 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 supplies provided on June 12, 2023, by an out-
of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Fulphila (Q5108). 
 
You asked the Plan to pre-approve Fulphila. You say that the patient is starting chemotherapy and meets the 
criteria for coverage. The Plan denied your request. The Plan says that this G-CSF drug is not being prescribed 
for a medically accepted indication. 
 The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use. Medicare rules 
also say that the administration of a G-CSF drug can be provided if the LCD criteria listed in the Medicare 
rules section of this letter are met. 
 
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 Fulphila. Our reviewer says that 
Fulphila is medically reasonable and necessary for this patient. Our physician reviewer found the requested use 
of Fulphila (Q5108) is FDA-approved for the enrollees diagnosis, given age and prior chemotherapy with this 
regimen the risk of neutropenic fever is likely greater than 20%. The documentation supports that the requested 
drug is safe and effective and otherwise reasonable and necessary for the patient. Our reviewer also found that 
the enrollee is more than 65 years old, has a history of previous chemotherapy or radiation therapy, and has 
advanced cancer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Fulphila have been met. Therefore, we decided that the Plan has to pre-approve 
Fulphila (Q5108).  
 
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 the laboratory services provided on July 11, 2023, to July 14, 
2023, by an out-of-network (OON) provider.  
 
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 were rendered by an out-of-network provider without prior authorization. 
 
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 laboratory services provided on July 11, 2023, 
to July 14, 2023, 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 provided on July 17, 2023. 
 
You asked the Plan to pay for the drug testing. You say that this testing was medically necessary. 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. 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). Therefore, we decided that the Plan does not have to pay for the drug testing 
provided on July 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 94375, 94727, 94729, and A4556 billed for 
date of service December 1, 2022. 
 
You asked the Plan to pay for the billed services. You say that the services were provided in good faith. The 
Plan denied your request. The Plan says the diagnosis codes do not support medical necessity. 
 
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 A4556 is electrodes, (e.g., apnea monitor), per pair. We 
find that CPT code A4556 has a status indicator of P. This means that the code is not separately payable.  
 
We find that codes 94375, 94727, and 94729 are not supported. The records show that the pulmonary function 
testing was provided as screening testing prior to surgery. This testing is not covered for screening services. 
Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 94375, 94727, 94729, and 
A4556 billed for date of service December 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the x-ray provided on August 30, 2023. 
 
You asked the Plan to reduce the copayment for the x-ray. You say that the Plan should have paid a portion of 
this service. 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 $45 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $45 copayment for the x-ray. This item/service falls within the 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. However, since the allowed amount is less than the standard copayment, you only owe $43.08. Therefore, we decided that the Plan does not have to reduce the copayment 
for the x-ray provided on August 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 28, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. 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 May 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99214 billed for date of service January 23, 2023. 
 
You asked the Plan to pay for code 99214. You say that this claim has never before been submitted to or paid 
by the Plan. The Plan denied your request. The Plan says you did not supply medical records to support 
payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of code 99214 have been met. In this 
case, you have provided no medical records to support the provision and billing of these services. The Plan 
requested these records from you multiple times without response.  Without these records, we cannot determine 
that these services were performed or billed correctly. Therefore, we decided that the Plan does not have to pay 
for code 99214 billed for date of service January 23, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 13101 rendered on October 28, 2022. 
 
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 that the records do not support the services 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. In this case, the CPT Code Manual definition of 
code 13101 is "Repair, complex, trunk; 2.6 cm to 7.5 cm." 
 
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 the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the procedure report describes an 
intermediate closure with layered closure with sutures and staples. This is not considered inclusive to the 
primary procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
procedure code 13101 rendered on October 28, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.