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

 
We decided that the Plan does not have to reduce the coinsurance for the radiation therapy provided on 
September 11, 2023. 
 
You asked the Plan to reduce the coinsurance for the radiation therapy. You say that you are asking for the 
charges to 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay 20% coinsurance for the radiation therapy. 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. The total amount you owe is $479.40, which is 
20% coinsurance of the allowed amount for each item. Therefore, we decided that the Plan does not have to 
reduce the coinsurance for the radiation therapy provided on September 11, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Botox provided on September 26, 2023. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of Botox in the setting of Raynaud's Disease has not 
been demonstrated in the peer-reviewed literature. 
 
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 pay for the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that the review indicates that the enrollee has a diagnosis of bilateral hand vasospasm/Raynaud's disease associated with 
systemic lupus erythematosus (SLE). There is associated ulceration and necrosis with failure of Amlodipine 
treatment. The clinical value and effectiveness of Botox in the setting of Raynaud's Disease has not been 
demonstrated in the literature The review has determined that. the requested use of Botox is not FDA-approved 
for the enrollees diagnosis. Its use is not supported by one of the major drug compendia or by clinical research 
that appears in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for Botox provided on September 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on October 19, 
2023. 
 
You asked the Plan to pay for the subsequent nursing facility care. 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 subsequent nursing 
facility care provided on October 19, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
March 29, 2023, to April 11, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that if the provider is 
billing, you can dispute with the plan. 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 $360 
copayment for inpatient hospital care.  
You have been asked to pay a $360 copayment for the inpatient hospital stay. This item/service falls within the 
inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. You have been asked to pay a total of $1,800 for the inpatient hospital stay ($360 
copayment x 5 days = $1,800). You have not been charged for the day you were discharged. Therefore, we 
decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on March 
29, 2023, to April 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on August 09, 2023. 
 
You asked the Plan to pay for wound care supplies. You say that you are requesting reconsideration for 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 wound care supplies 
provided on August 09, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 29, 2023. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary and serves as 
an early detection tool. 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 June 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on February 16, 2023, billed 
with procedure code 01992. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim is not billed with an appropriate 
diagnosis code.  
 
The Plan must follow Medicare rules. Medicare rules say that it is not appropriate to bill Medicare for services 
that are not covered as if they are covered. When anesthesia codes are used and MAC has been provided, the 
QS modifier must be used.  
We looked at the file and Medicare rules. This claim has not been billed with a diagnosis from the list of 
covered diagnoses and has not been billed with the required QS modifier. Based on this information, we 
decided that Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we 
decided that the Plan does not have to pay for practitioner services provided on February 16, 2023, billed with 
procedure code 01992.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services described by code 01992 performed 
on date of service February 14, 2023. 
 
You asked the Plan to pay for 01992. You say that 01992 should be paid as billed because it is supported in the 
medical record and the diagnosis code assigned is reimbursable. The Plan denied your request. The Plan says 
01992 is denied because it was billed without the required -QS modifier, and it was billed with a diagnosis 
code that does not support medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that when MAC is provided and procedure code 
01992 is billed, modifier -QS must be used. The rules also say that diagnosis code M54.16 is not listed as a 
diagnosis code that supports medical necessity when billing procedure code 01992.  
We looked at the file and Medicare rules. In this case, the medical records contain evidence that MAC was 
provided. We confirmed that procedure code 01992 was billed without modifier -QS. Modifier -QS is required 
when reporting 01992 when MAC is provided. We have also confirmed that procedure code 01992 was billed 
with diagnosis code M54.16, defined as radiculopathy, lumbar region. No additional diagnoses were listed on 
the claim. Per LCA A57361, M54.16 does not support medical necessity when billing 01992. As such, the 
denial of 01992 is appropriate. Based on this information, we decided that Medicare rules for coverage of 
01992 have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services 
described by code 01992 performed on date of service February 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel rendered on 
September 22, 2023. 
 
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 not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that a test panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. The file shows that the test panel was not billed as a single unit of 
service. 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 pay for the urine polymerase chain reaction (PCR) 
panel rendered on September 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient surgery provided on October 7, 2022. 
 
You asked the Plan to pay for an outpatient surgery. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says the requested service is considering to be 
experimental or investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for an outpatient surgery. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that it was clearly documented that "no prior authorization required" could mean that you 
would have to pay for the procedure out of pocket and that some insurance companies view this procedure as 
investigational. After reviewing the literature provided by the manufacturer on their website, the reviewer agrees with the assessment that the Sprint PNS System has no peer-reviewed literature to support its use in the 
setting of chronic shoulder pain. 
 
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 outpatient surgery have not been met. Therefore, we decided that the Plan 
does not have to pay for an outpatient surgery provided on October 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 7, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the lab 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 lab services provided on July 7, 2023, by an out-of-network 
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87500, 87641, 87798, G0452, 87471, 
87481, 87551, 87651, and 87653 provided on September 14, 2023. 
 
You asked the Plan to pay for procedure codes 87500, 87641, 87798, G0452, 87471, 87481, 87551, 87651, and 
87653. 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 for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure codes 87500, 87641, 87798, G0452, 87471, 87481, 87551, 87651, and 
87653 provided on September 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator (E1390) and Portable gaseous 
oxygen system, rental (E0431) provided September 6, 2023. 
 
You asked the Plan to pay for the oxygen equipment. You say that the medical records provided support the 
necessity of the services in dispute The Plan denied your request. The Plan says this service is not covered. 
Medicare rental payments for oxygen equipment stop after 36 months of continuous use. 
 The Plan must follow Medicare rules. These rules say that there is no further payment for oxygen equipment 
during the 5-year reasonable useful lifetime (RUL) of the equipment after 36 rental payments have been made. 
 
We looked at the file and Medicare rules. The oxygen equipment was delivered on May 19, 2019. The enrollee 
has used oxygen for more than 36 months. Medicare rental payments for oxygen equipment stop after 36 
months of continuous use. Based on this information, we decided that Medicare rules for coverage of the 
oxygen equipment have not been met. Therefore, we decided that the Plan does not have to pay for the oxygen 
concentrator (E1390) and Portable gaseous oxygen system, rental (E0431) provided September 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the lab testing provided on September 22, 
2023. 
 
You asked the Plan to waive the copayment for the lab testing. You say that you should not be responsible for 
any balance. 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 outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $10 copayment for the lab testing. 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 waive the 
copayment for the lab testing provided on September 22, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on August 10, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not supported. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. You were referred for the laboratory services by a contract provider. The file does 
not show that the Plan provided notice that the laboratory services would not be covered. Under Medicare 
rules, this means the laboratory services are considered approved by the Plan.  
 
Additionally, the rules also 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, it is the plans responsibility to show that its decision to deny coverage is correct. Records 
from a plan provider are considered to be within the control of the plan. In cases where the plan has not 
supplied records from a plan provider that are critical to its decision, we may properly find that the denial is not 
medically appropriate or justifiable. Enrollees should not be penalized for a plans failure to obtain records that 
are within the plans control. The plan did not provide sufficient medical records in order to determine if the 
enrollee meets Medicare criteria for the laboratory services provided. Therefore, we decided that the Plan has to 
pay for the laboratory services provided on August 10, 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 pay for the supplies billed with code A4239 for September 22, 2023. 
 
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 exceed the benefit limit. 
 
The Plan must follow Medicare rules. The rules say that only one (1) month, thirty (30) days of the supply 
allowance may be billed at a time. 
 
We looked at the file and Medicare rules. The file shows that the Plan paid for a one month supply of code 
A4239 prior to the date of service at issue and additional units cannot be approved. 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 pay for the supplies billed with code A4239 for September 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (62321). 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that ESI will be considered medically reasonable and 
necessary when certain requirements 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 an epidural steroid injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the criteria for a 
successful ESI is 3 months of 50% pain relief. This was not achieved and therefore, the request is deemed not 
medically reasonable and 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 an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection (62321).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospice services provided on March 15, 2023. 
 
You asked the Plan to pay for hospice services. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospice services provided on March 15, 2023.