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

 
We decided that the Plan does not have to pay for procedure code J3490 rendered on March 8, 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 payment is included in the global package.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that procedure code J3490 is not supported in the medical record. Specifically, these drugs were 
provided on the same day as a minor surgery and would be included in the payment for this surgery. CPT 
20610 has a global surgery value of 000, meaning that some services on the same day are included in the 
payment for CPT 20610. 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 code J3490 
rendered on March 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint radiofrequency ablation. 
 
You asked the Plan to pre-approve facet joint radiofrequency ablation. You say that the procedure is necessary 
as a permanent solution to pain, which is affecting your ability to walk and get up on your own.  The Plan 
denied your request. The Plan says that not all conditions are met for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation may be covered under certain 
circumstances. 
 
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 facet joint radiofrequency ablation. Our 
reviewer says that the records do not show that the requested treatment is medically reasonable and necessary. 
Our physician reviewer found that the records did not show that you have met the coverage criteria. You had 
bilateral L4-L5, L5-S1 medial branch blocks on May 26, 2023, with less than 80% improvement in symptoms. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint radiofrequency ablation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve facet joint radiofrequency ablation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 20, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that the provider has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on January 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for manual therapy techniques, therapeutic activities and 
application of a modality provided on January 19, 2023. 
 
You asked the Plan to pay for manual therapy techniques, therapeutic activities and application of a modality. 
You say that you have soreness in your right hip every day and some days you can hardly walk as the pain 
affects your knees and your feet. The Plan denied your request. The Plan says only manual manipulation of the 
spine to correct subluxation is covered.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for manual therapy techniques, therapeutic activities and application of a 
modality provided on January 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 reader and sensors.  
You asked the Plan to pre-approve the Freestyle Libre 2 reader and sensors. You say that you need the monitor 
because it will be so much easier and less painful to check your sugar.  The Plan denied your request. The Plan 
says you do not meet coverage criteria for the requested CGM sensors/monitor.  
 
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 Freestyle Libre 2 reader and 
sensors. Our reviewer says that the Freestyle Libre 2 reader and sensors are not medically necessary. Our 
physician reviewer found coverage for CGM include either insulin use or low blood glucose sugar. You are not 
using insulin and are not having low blood glucose sugar episodes we are told of. In fact, the medications you 
take usually do not cause low blood sugar. Although the CGM might help you with diet compliance, coverage 
for the CGM is not met 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 the Freestyle Libre 2 reader and sensors have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Freestyle Libre 2 reader and sensors.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 30, 2022. 
 
You asked the Plan to pay for an office visit. You say that the services should be covered. 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 an office visit provided 
on November 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for visual field examination provided on February 14, 2023. 
 
You asked the Plan to pay for visual field examination. You say that this service is supported in the records. 
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 visual field examination 
provided on February 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on January 
23, 2023, to January 24, 2023. 
 
You asked the Plan to waive the copayment for a specialist 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 $45 
copayment for physician/practitioner services/specialist. 
 
You have been asked to pay a $45 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist 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, you are only being asked to pay a $40 per visit which is less than 
the required amount. The total amount you are being asked to pay is $80 ($40 x 2 visits = $80). Therefore, we 
decided that the Plan does not have to waive the copayment for a specialist office visit provided on January 23, 
2023, to January 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laryngoscopy services provided on March 14, 2023. 
 
You asked the Plan to pay for laryngoscopy services. You say that authorization is not required for these 
services. 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 laryngoscopy services 
provided on March 14, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for an ultrasound provided on July 11, 2022. 
 
You asked the Plan to reduce the coinsurance for an ultrasound. You say that you were told that you would 
receive $20 off your bill. 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 up to $75 per day, for Medicare-covered diagnostic radiology services.  
 
 
 
 You have been asked to pay $75, which is less than 20% coinsurance of the allowed amount for an ultrasound. 
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. Therefore, we 
decided that the Plan does not have to reduce the coinsurance for an ultrasound provided on July 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital outpatient clinic visit for assessment and 
management provided on December 14, 2022, to April 27, 2023. 
 
You asked the Plan to pay for hospital outpatient clinic visit for assessment and management. You say that the 
services should be covered. 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 hospital outpatient clinic 
visit for assessment and management provided on December 14, 2022, to April 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on November 
02, 2022. 
 
You asked the Plan to pay for an office visit and related services. You say that the services should be covered. 
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 an office visit and 
related services provided on November 02, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the hospital clinic visit, and the knee 
injection provided on January 31, 2023. 
 
You asked the Plan to waive the copayments for the clinic visit and the injection. 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 $385 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital.  
 
 
 You have been asked to pay a $78.79 copayment for the clinic visit. You have also been asked to pay a $306.21 
copayment for the injection. The total amount you owe is $385 ($78.79 copayment + $306.21 copayment = 
$385). This item/service falls within the outpatient surgery and other medical 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. Therefore, we decided that the Plan does not have to waive the copayments for the hospital clinic 
visit, and the knee injection provided on January 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a portable oxygen system and an oxygen 
concentrator provided on December 9, 2022, and January 9, 2023 
 
You asked the Plan to waive the coinsurance for a portable oxygen system and an oxygen concentrator. You 
say that you say that you returned the equipment. 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-covered durable medical equipment and supplies. You have been asked to pay $5.39, which is 20% coinsurance of the allowed amount for the portable oxygen 
system provided on December 9, 2022 ($26.96 allowed amount x 20% = $5.39). You have also been asked to 
pay $5.87, which is 20% coinsurance of the allowed amount for the portable oxygen system provided on 
January 9, 2023 ($29.34 allowed amount x 20% = $5.87). You have also been asked to pay $30.23, which is 
20% coinsurance of the allowed amount for the oxygen concentrator provided on December 9, 2022 ($151.15 
allowed amount x 20% = $30.23). You have also been asked to pay $32.90, which is 20% coinsurance of the 
allowed amount for the oxygen concentrator provided on January 9, 2023($164.48 allowed amount x 20% = 
$32.90). These items/services fall 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. Therefore, we decided that 
the Plan does not have to waive the coinsurance for a portable oxygen system and an oxygen concentrator 
provided on December 9, 2022, and January 9, 2023
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets admission criteria. The Plan 
denied your request. The Plan says the IRF services you are requesting do not meet the requirements for 
approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 14, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the 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 an office visit provided on December 14, 2022, by 
an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on October 25, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you feel 
this should be covered, as it was during an emergency, and it was of no control of your own that there were no 
available paramedics. The Plan denied your request. The Plan says this service is not covered. 
 
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 October 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 (A0998) provided on October 25, 2022.  
 
Please Note: The record shows that two ambulances were dispatched to your location on this date of service. It 
appears that one, under claim number ending in 2341, was covered by the Plan, and you are responsible for a 
$290 copayment. Please follow up with the Plan if you have additional questions about this.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the hospital observation services provided 
on February 25, 2023. 
 
You asked the Plan to waive the cost sharing for the hospital observation services. You say that you think that 
the cost sharing should be lower. 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 $750 deductible which applies to outpatient hospital observation 
services, and that you must pay a $125 copayment after the deductible is met for outpatient hospital 
observation services. 
 You have been asked to pay a $675.21 deductible for the hospital observation services. You have also been 
asked to pay a $125 copayment for the hospital observation services. The items or services you asked the Plan 
to waive the cost sharing for fall within the outpatient hospital observation benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to 
outpatient hospital observation. This cost sharing is a contractual obligation that had not been met at the time 
the hospital observation services were provided on February 25, 2023. Therefore, we decided that the Plan does 
not have to waive the cost sharing for the hospital observation services provided on February 25, 2023.