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

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service September 22, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that this should be paid for. The Plan denied 
your request. The Plan says code 99153 is not payable in the facility setting.  
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.   
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service September 22, 2022, 
billed with code 99153.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the colonoscopy provided on January 31, 
2023. 
 
You asked the Plan to waive the cost share for the colonoscopy. You say that your coinsurance should only be 
$22.49. 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. Your 
contract with the Plan says that there is a $800 deductible which applies to surgery, including services provided 
at a hospital outpatient facility. Your contract with the Plan also clearly says that you must pay 10% 
coinsurance for surgery services. You have been asked to pay $800, which satisfies your deductible for the colonoscopy. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $800 deductible which applies to surgery, 
including services provided at a hospital outpatient facility. This cost sharing is a contractual obligation that 
had not been met at the time the colonoscopy was received on January 31, 2023.  
 
You have also been asked to pay $102.09, which is 10% coinsurance of the allowed amount for the 
colonoscopy ($1,020.92 allowed amount x 10% = $102.09). you have been asked to pay a total of $902.09 
($800 deductible + $102.09 coinsurance = $902.09). This item/service falls within the surgery, including 
services provided at a hospital outpatient facility 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 
cost share for the colonoscopy provided on January 31, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for piflufolastat provided on December 16, 
2022. 
 
You asked the Plan to waive the coinsurance for piflufolastat. You say that you were advised the copayment for 
the imaging would only be $105 and you are unable to afford the cost share applied. 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 outpatient diagnostic test. 
 
You have been asked to pay 20% coinsurance for piflufolastat. This item/service falls within the outpatient 
diagnostic test 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 total you owe is 949.32, which is 20% of the allowed amount for the chemical agent, piflufolastat 
($4,746.58 allowed x 20% = $949.32). Therefore, we decided that the Plan does not have to waive the 
coinsurance for piflufolastat provided on December 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Gallium illuccix provided on August 23, 
2022. 
 
You asked the Plan to waive the coinsurance for Gallium illuccix. You say that diagnostic radiology is a 
covered benefit under your plan and you should only have a $110 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 20% 
coinsurance for outpatient diagnostic test. 
 
You have been asked to pay 20% coinsurance for Gallium illuccix. This item/service falls within the outpatient 
diagnostic test 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 total you owe is $1,674.20, which is 20% of the allowed amount for medical supply, Gallium illuccix 
($8,371.02 allowed x 20% = $1,674.20). Therefore, we decided that the Plan does not have to waive the 
coinsurance for Gallium illuccix provided on August 23, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections on February 10, 2022, to July 
28, 2022. 
 
You asked the Plan to waive the coinsurance for injections. You say that you want to appeal the amount being 
charged. 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 20% 
coinsurance for chemotherapy/radiation drugs, biologicals and other drugs covered by Medicare Part B  
including their administration and all chemotherapy services. These drugs are covered under Part B of Original 
Medicare. Members of the plan receive coverage for these drugs through our plan. Covered drugs include drugs 
that usually aren't self-administered by the patient and are injected or infused while you are getting physician, 
hospital outpatient, or ambulatory surgical center services. For date of service February 10, 2022, the allowed 
amount is $36.06. For date of service March 24, 2022, the allowed amount is $135.81. For date of service May 
5, 2022, the allowed amount is $127.14. For date of service June 16, 2022, the allowed amount is $126. 93. For 
date of service July 28, 2022, the allowed amount is $125.21. $36.05 + $135.81 + $127.14 + $126.93 + 
$125.21 = $551.14. Therefore, results in the total cost sharing amount of $551.14. 
 
You have been asked to pay a 20% coinsurance for injections. This item/service falls within the Medicare Part 
C 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 injections on 
February 10, 2022, to July 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the specialist office visit and the eye exam 
provided on January 10, 2023. 
 
You asked the Plan to waive the deductible for the specialist office visit and the eye exam. You say that your 
cost share exceeds your deductible. 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. Your 
contract with the Plan says that there is a $400 deductible which applies to vision services.  
 
 
 
 You have been asked to pay $162.91 towards the deductible for the specialist office visit. You have also been 
asked to pay $39.77 towards the deductible for the eye exam. The items or services you asked the Plan to waive 
the deductible for fall within the vision services benefit category. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $400 deductible which applies to vision services. This cost 
sharing is a contractual obligation that had not been met at the time the specialist office visit and the eye exam 
was received on January 10, 2023. Therefore, we decided that the Plan does not have to waive the deductible 
for the specialist office visit and the eye exam provided on January 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95885, 95908, 95937 and 95955 rendered 
on August 4, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the 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 95885: 
 
Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary 
procedure) 
 
CPT 95908: 
 
Nerve conduction studies; 3-4 studies 
 
CPT 95937: 
 
Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method 
 
CPT 95955: 
 
Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery) 
 
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 95885 and 
95908, the procedure report describes pedicle screw stimulation, which would not be reported with nerve 
conduction which measures amplitude and latency/velocity. In this case, these procedures cannot be verified. In 
terms of CPT 95937, the procedure report describes train of four testing, which would not be reported with 
neuromuscular junction testing. No code exists for train of four as this procedure is included in the primary 
neuromonitoring procedure. Finally, in terms of CPt 95955, the procedure report describes neuromonitoring 
provided for decompression (Laminectomy, laminoplasty, foraminotomy, facetetomy) L4 - S1, TLIF L3 - L5. 
In this case, there is a more appropriate code to report for service provided. 
 
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 95885, 95908, 95937 and 95955 rendered on August 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on November 25, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. The Plan denied your 
request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on November 25, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on November 25, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Gammagard. 
 
You asked the Plan to pre-approve Gammagard. You say that the enrollee had a kidney transplant and needs 
the medication. The Plan denied your request. The Plan says that Gammagard is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Gammagard. Our reviewer says that 
Gammagard is medically necessary. Our physician reviewer found that the enrollee had a kidney transplant and 
has been diagnosed with BK viremia. Treatment of BK viremia in transplant patients is important because by 
the time finding can be found in a biopsy, irreversible damage may have been done. The allograft will then be 
at risk for premature failure, so the treatment of BK viremia is medically 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 Gammagard have been met. Therefore, we decided that the Plan has to pre-
approve Gammagard.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the specialist visits provided from 
November 24, 2022, to November 26, 2022, and the hospital observation provided on November 23, 2022. 
 
You asked the Plan to waive the copayments for the specialist visits and the hospital observation. You say that 
you were told that you were admitted to the hospital. 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 $35 
copayment for each in-person specialist visit. Your contract with the Plan clearly says that you must pay a $225 
copayment for outpatient hospital observation services. 
 
You have been asked to pay a $35 copayment for each specialist visits provided on November 24, 2022, 
November 15, 2022, and November 26, 2022. These items/services fall within the physician/practitioner 
services, including doctor's office visits benefit category. You have also been asked to pay a $225 copayment 
for the hospital observation services provided on November 23, 2022. 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 copayments for 
the specialist visits provided from November 24, 2022, to November 26, 2022, and the hospital observation 
provided on November 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you want to see this provider as your full-time 
primary care provider (PCP), as you are unsatisfied with your current one. The Plan denied your request. The 
Plan says this is an out-of-network specialist, they cannot become a PCP. Please chose from the Plan's in-
network list of PCPs what are 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 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 office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary. The Plan denied your request. The Plan says the requested epidural steroid injection does 
not meet the Medicare LCD coverage criteria.  
 
The Plan follows Medicare rules. 
 
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 an epidural steroid injection. Our 
reviewer says that the requested epidural steroid injection is not considered medically necessary in this case. 
Our physician reviewer found that in this case there are no radicular findings on the exam. The review indicates 
that the requested epidural steroid injection does not meet the Medicare LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy provided on September 8, 2022. 
 
You asked the Plan to pay for infrared therapy. The Plan denied your request. The Plan says infrared therapy is 
considered not reasonable and necessary by Medicare and is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to conclude the use of 
infrared therapy devices and any related accessories is not reasonable and necessary under section 
1862(a)(1)(A) of the Social Security Act (the Act).  
 
We looked at the file and Medicare rules. Medicare says say that there is sufficient evidence to conclude the 
use of infrared therapy devices and any related accessories is not reasonable and necessary. Therefore, we 
decided that the Plan does not have to pay for infrared therapy provided on September 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sensor and receiver for a continuous glucose monitor.  
You asked the Plan to pre-approve the sensor and receiver for a continuous glucose monitor. You say that the 
medical records support the medical necessity for the sensor and receiver for a continuous glucose monitor. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested sensor and 
receiver. 
 
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 sensor and receiver for a continuous 
glucose monitor. Our reviewer says that the sensor and receiver for a continuous glucose monitor are not 
medically necessary. Our physician reviewer found the enrollee is not having low blood glucose sugar and is 
not using insulin. The enrollee is not on a medication that causes low blood glucose sugar. We are also  not told 
why a glucometer would not suffice. 
 
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 sensor and receiver for a continuous glucose monitor. 
 have not been met. Therefore, we decided that the Plan does not have to pre-approve a sensor and receiver for 
a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transplant evaluation to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve transplant evaluation. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says if the enrollee needs Medicare-covered medical care and a network 
provider is unable to provide this care, the enrollee may be able to get care from an out-of-network provider. 
The plan must confirm there is not a network provier available, and the out-of-network provider must contact 
the plan to request an authorization for the enrollee to obtain services. If approved, the out-of-network provider 
will be issued an authorization to provide the service(s). 
 
 
 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 
transplant evaluation to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy, and related services provided on October 
06, 2022. 
 
You asked the Plan to pay for physical therapy, and related services. You say that these services were 
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 physical therapy, and 
related services provided on October 06, 2022.