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

 
We decided that the Plan does not have to waive the copayments for an in-network podiatry visit, a foot x-ray, 
and a magnetic resonance imaging (MRI) scan provided from March 28, 2023, to April 3, 2023. 
 
You asked the Plan to waive the copayments for an in-network podiatry visit, a foot x-ray, and MRI. You say 
that you had terrible treatment at these facilities and should not have to pay these copayments. 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 a specialist, a $20 copayment for Medicare-covered x-ray services, and a $270 copayment for 
Medicare-covered diagnostic radiology services.  
 You have been asked to pay the allowed amount of $219.34 which is less than the $270 copayment for an MRI. 
Between these services, you have been asked to pay a total copayment amount of $284.34 ($45 + $20 + 
$219.34 = $284.34). 
 
You have been asked to pay a $284.34 total copayment for an in-network podiatry visit, a foot x-ray, and MRI. 
This item/service falls within the copayment for a specialist, for Medicare-covered x-ray services and 
Medicare-covered diagnostic radiology 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 
copayments for an in-network podiatry visit, a foot x-ray, and a magnetic resonance imaging (MRI) scan 
provided from March 28, 2023, to April 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that you were given insulin during your last hospital stay 
as they did not give metformin. You also say that you have to take insulin twice a day with testing. The Plan 
denied your request. The Plan says the notes indicate you want this so you do not have to poke your finger for 
sugar checks. The Plan also says there were no records provided to show that you are treated with insulin. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 the CGM have been met. Specifically, 
there were no medical records provided to support the need for the requested CGM. Therefore, we decided that 
the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chronic care management services provided on April 30, 
2023, by an OON provider.  
 
You asked the Plan to pay for the chronic care management services. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says this service was 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 chronic care management services provided on 
April 30, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on April 25, 2023. 
 
You asked the Plan to pay for a home visit. You say that the provider was not responsible for obtaining 
authorization. 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 a home visit provided on 
April 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87801, 87150, and 87641 provided on 
December 13, 2022. 
 
You asked the Plan to pay for procedure codes 87801, 87150, and 87641. 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 
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. 
 
In this case, the CPT Code Manual definition of code 87801 is Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified probe(s) technique. The definition of code 87150 is Culture, typing; 
identification by nucleic acid (DNA or RNA) probe, amplified probe technique, per culture or isolate, each 
organism probed. The definition of code 87641 is Infectious agent detection by nucleic acid (DNA or RNA); 
Staphylococcus aureus, methicillin resistant, amplified probe technique. 
 
We find that CPT code 87801 is not supported in the medical record. Specifically, the records do not support 
that multiple organisms were tested via amplified probe(s) technique. The file supports that 1 unit of procedure 
code 87801 was provided; however, the provider billed 3 units incorrectly. Furthermore, the records do not 
support the billing of procedure code 87150. Specifically, the laboratory report includes documentation 
regarding the methodology (PCR) for the assay panel performed but does not describe culture and typing by 
nucleic acid probe. There is one report submitted for review and no results are provided for CPT 87150. Lastly, 
the records do not support the billing of procedure code 87641. Specifically, procedure code 87641 is described 
as an infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, methicillin resistant 
amplified probe technique when performed. The laboratory results provided indicates the testing of other 
amplified infectious agents were performed, but it does not include separate testing results to meet the code 
criteria of CPT 87641. Based on this information, we decided that Medicare rules for coverage of procedure 
codes 87801, 87150, and 87641 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 87801, 87150, and 87641 provided on December 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the requested CGM is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
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 CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the coverage criteria for a CGM 
requires insulin use or low blood sugars. This enrollee is not using insulin and not having low blood sugars that 
we are told of. The enrollee is also not on medications that typically cause low blood sugars. Although, the 
CGM may help the enrollee, the coverage criteria are not met based on the policy criteria given above. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on April 4, 2023, by an OON 
provider.  
 
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 this service was 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 drug testing provided on April 4, 2023, by an 
OON provider.
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 these services. You say that you disagree with the denial The Plan denied 
your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found you have a diagnosis of osteoporosis. 
The records show that you have not tried and failed the Plan's required drugs, alendronate, risedronate, or 
ibandronate and zoledronic acid or Prolia. The records do not show that the required drugs would have adverse 
effects or be less effective; therefore, Evenity is not reasonable or medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Evenity.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 19, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that this service was medically necessary. The Plan 
denied your request. The Plan says there were network providers available. 
 
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 provided on December 19, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an OON provider.  
 
You asked the Plan to pre-approve the office visit. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says this service can be provided by an in-
network provider. 
 
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 record shows you are 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 the office visit 
to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on February 14, 2023. 
 
You asked the Plan to pay for the wound care supplies. You say that you are requesting reconsideration of the 
denied claim. 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 wound care supplies 
provided on February 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the vestibular therapy to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve the therapy. You say that you are requesting reconsideration of the denied 
service. The Plan denied your request. The Plan says this service was not approved. 
 
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 
the vestibular therapy to be provided by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 57250 billed for date of service February 6, 
2023.  

You asked the Plan to pay for procedure code 57250. You say that this service is supported in the medical 
record. The Plan denied your request. The Plan says payment for code 57250 is bundled into payment for code 
57240. 
 
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, we have confirmed that code 57250 
is a column II code to column I code 57240 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 57250 billed for date of service February 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral lower extremity revascularization, 
endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placements 
and atherectomy, includes angioplasty (37224, 37225, 37226, 37227). 
 
You asked the Plan to pre-approve bilateral lower extremity revascularization, endovascular, open or 
percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placements and atherectomy, 
includes angioplasty. You say that this is medically necessary. The Plan denied your request. The Plan says 
there is no hemodynamically significant disease in the femoral/popliteal territories of either leg. The degree of 
stenosis in femoral/popliteal is less than 20%, therefore the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that this item or service is covered under certain 
conditions. 
 
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 bilateral lower extremity 
revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal 
stent placements and atherectomy, includes angioplasty. Our reviewer says that the documentation does not 
support the medical necessity of the procedures in question and does not meet coverage criteria. Our physician 
reviewer found the enrollee presents for follow up without any other complaint. The description of symptoms is 
not sufficiently detailed on which to make a determination that intervention is medically necessary. No ankle-
brachial index result is documented. What is documented are normal pedal pulses bilaterally. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bilateral lower extremity revascularization, endovascular, open or percutaneous, 
femoral, popliteal artery(s), unilateral; with transluminal stent placements and atherectomy, includes 
angioplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral 
lower extremity revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; 
with transluminal stent placements and atherectomy, includes angioplasty (37224, 37225, 37226, 37227).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for colonoscopy provided on June 09, 2023. 
 
You asked the Plan to waive the copayment for colonoscopy. You say that you say that you thought that the 
colonoscopy would be covered 100%. 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 $390 
copayment for outpatient hospital observation. 
 
You have been asked to pay a $390 copayment for colonoscopy. This item/service falls within the outpatient 
hospital observation 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 colonoscopy 
provided on June 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on May 22, 2023. 
 
You asked the Plan to waive the copayment for an office visit. 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 $10 
copayment for in-network physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $10 copayment for an office visit. This item/service falls within the in-network 
physician/practitioner services, including doctors office visits 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 an office visit provided on May 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99222 billed for date of service November 17, 2022. 
 
You asked the Plan to pay for code 99222. You say that the medical records support payment of this code. The 
Plan denied your request. The Plan says code 99222 is not supported by the medical records. The records don't 
support a comprehensive history. 
 
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 99222 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: a comprehensive history; a 
comprehensive examination; and medical decision making of moderate complexity. Counseling and/or 
coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) 
and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of moderate severity. 
Physicians typically spend 50 minutes at the bedside and on the patient's hospital floor or 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 code 99222. Our reviewer says that code 99222 is not 
supported by the medical record. Our reviewer found the enrollee was a then 79-year-old male with a history of 
hepatocellular carcinoma, hypertension, cerebrovascular accident, and benign prostatic hyperplasia who 
presented to the emergency room with gross hematuria. He was evaluated and seen by urology. A Foley 
catheter was placed, and he was admitted. However, code 99222 was not supported by the medical 
records.  The records did not support a comprehensive history. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99222 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99222 billed for date of service November 17, 2022.