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

 
We decided that the Plan does not have to pre-approve a complete two-dimensional transthoracic 
echocardiography (TTE) with color flow Doppler and a single photon emission computed tomography 
(SPECT) for myocardial perfusion with multiple studies. 
 
You asked the Plan to pre-approve a complete two-dimensional transthoracic echocardiography (TTE) with 
color flow Doppler and a single photon emission computed tomography (SPECT) for myocardial perfusion 
with multiple studies. The Plan denied your request. The Plan says there is no exam, assessment, or plan to 
determine medical necessity despite attempts for additional clinicals. 
 
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 a complete two-dimensional 
transthoracic echocardiography (TTE) with color flow Doppler and a single photon emission computed 
tomography (SPECT) for myocardial perfusion with multiple studies have been met. There is no exam, 
assessment, or plan to determine medical necessity. Therefore, we decided that the Plan does not have to pre-
approve a complete two-dimensional transthoracic echocardiography (TTE) with color flow Doppler and a 
single photon emission computed tomography (SPECT) for myocardial perfusion with multiple studies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 10, 2023. 
 
You asked the Plan to pay for an office visit. You say that you would like a 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 an office visit provided 
on January 10, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the definitive urine drug testing (UDT) for 15-21 drug classes (G0482).  
 
You asked the Plan to pay for the definitive UDT for 15-21 drug classes. You say that ordering a multi-class 
panel of definitive urine drug tests that are not used in clinical management, exceeds the needs of the enrollee. 
The Plan denied your request. The Plan says that under Medicare rules, the number of definitive urine drug 
classes requested are not medically necessary.  
 
The Plan follows Medicare rules. Medicare rules say that this testing is covered when the criteria in the rules 
section of this letter are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the definitive UDT for 15-21 drug classes. 
Our reviewer says that this service was medically necessary. Our physician reviewer found that the enrollee 
had one illicit substance and one non-prescribed medication. The presence of 2 inconsistent drugs suggests it 
was medically reasonable and necessary to conduct definitive testing. 
 
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 definitive UDT for 15-21 drug classes have been met. Therefore, we 
decided that the Plan has to pay for the definitive urine drug testing (UDT) for 15-21 drug classes (G0482).   
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Integra BMWD (Q4104) provided on 
February 14, 2023. 
 
You asked the Plan to waive the copayment for Integra BMWD (Q4104). You say that you believe there was 
an error in how your services were billed. 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 in-network Medicare Part B covered drugs  Primary Care Providers (PCP) office  
Specialists office - Pharmacy. 
 
You have been asked to pay $780.39 for Integra BMWD (Q4104). The total amount allowed to be billed was 
$3,901.95. You have been asked to pay a $780.39 coinsurance for this service, which is 20% of the total 
allowed amount. This item/service falls within the Medicare Part B 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 copayment for Integra BMWD (Q4104) provided on February 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assessment and care planning services provided on February 
07, 2023. 
 
You asked the Plan to pay for assessment and care planning services. 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 assessment and care 
planning services provided on February 07, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit for the evaluation and 
management of a patient (99284) provided on January 27, 2023. 
 
You asked the Plan to pay for the service. You say that separate procedures were performed, the claim should 
be reprocessed. The Plan denied your request. The Plan says the provider did not bill as required by Medicare 
coding regulations. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. Review of the file shows that the 
emergency service is billed with an inappropriate place of service code: 21 (inpatient hospital). There is a more 
appropriate place of service code that needs to be billed. Therefore, we decided that the Plan does not have to 
pay for the emergency department visit for the evaluation and management of a patient (99284) provided on 
January 27, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an OON provider.  
 
You asked the Plan to pre-approve physical therapy. You say that you do not agree with the denial of the 
requested service. The Plan denied your request. The Plan says the 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 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 
physical therapy to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 20, 2023. 
 
You asked the Plan to pay for an office visit. You say that You were bounced between hospitals because they 
could not help you at the first one. Getting transferred was a last resort. 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 January 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on January 18, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the genetic testing. You say that you claim for the DecisionDx-SCC test was 
denied in error ad you are requesting it be reprocessed and paid. The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 
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. Also, DecisionDx-SCC is considered not medically necessary because of a lack of peer 
reviewed published literature supporting the tests clinical utility. This test has not been validated in peer 
reviewed medical literature. There is a lack of clinical validity and clinical utility when used in testing. 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 DecisionDx-SCC test (0315U) provided on January 18, 2023, by an out-of-
network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on July 16, 2022. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that your provider 
ordered an unnecessary CT scan and advised it would be covered. 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 $350 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $350 copayment for a computed tomography (CT) scan. 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. Therefore, we decided that the Plan does not have to waive the copayment for a 
computed tomography (CT) scan provided on July 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient hospital stay provided on November 28, 2022, to 
December 22, 2022. 
 
You asked the Plan to pay for an inpatient hospital stay. 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 an inpatient hospital stay 
provided on November 28, 2022, to December 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on March 15, 2023, and billed with codes 87150, 87798, and 87481. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was performed as ordered by the 
referring physician. The Plan denied your request. The Plan says this testing should be billed with a single 
panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
testing provided on March 15, 2023, and billed with codes 87150, 87798, and 87481.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic comprehensive preventive medicine 
reevaluation and management of an individual including an age and gender appropriate history, examination, 
counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic 
procedures, established patient; 40-64 years (99396) provided on April 5, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid with $0 member 
responsibility. The Plan denied your request. The Plan says you exhausted your benefit. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
Review of the file shows that EOC member is allowed one covered Pap test every 24 months. You were seen 
on April 1, 2021, and on April 5, 2022, for the same services. The exam on April 1, 2021, was processed and 
paid on April 24, 2021. The services billed for services rendered on April 5, 2022, exceed the 24-month 
benefit. Your 2022 EOC also states, "If you are at high risk of cervical or vaginal cancer or you are of 
childbearing age and have had an abnormal Pap test within the past 3 years: one Pap test every 12 months". 
However, this claim was billed with diagnostic diagnosis code Z01419- Encounter for gynecological 
examination (general) (routine) without abnormal findings. 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 service have not 
been met. Therefore, we decided that the Plan does not have to pay for the periodic comprehensive preventive 
medicine reevaluation and management of an individual including an age and gender appropriate history, 
examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of 
laboratory/diagnostic procedures, established patient; 40-64 years (99396) provided on April 5, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an OON provider.  
 
You asked the Plan to pre-approve physical therapy. You say that you do not agree with the denial for physical 
therapy at the facility you requested. The Plan denied your request. The Plan says the 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 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 
physical therapy to be provided by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a Medicare Part B drug provided on 
December 29, 2022. 
 
You asked the Plan to waive the cost share for a Medicare Part B drug. You say that you received your fourth 
treatment and was never charged a copayment for previous visits. 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 each Medicare-covered Part B drug.  
 
 
  You have been asked to pay $30 for a Medicare Part B drug. The amount owed is less than 20% of the allowed 
amount for the Part B drug ($217.89 allowed x 20% = $43.58). This item/service falls within the Medicare Part 
B 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 cost share for a Medicare Part B 
drug provided on December 29, 2022.
Appeal type: Step-Therapy
Decision: Favorable

 
We decided that the Plan has to pre-approve treatment with Gel-One (J7326). 
 
You asked the Plan to pre-approve Gel-One. You say that Gel-One is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says that step-therapy rules for coverage of Gel-One have not been 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 Gel-One. Our reviewer says that Gel-
One is medically reasonable and necessary in this case. Our physician reviewer found that the Plan requires a 
trial of drugs Synvisc, Synvisc-One or Orthovisc before they will approve the requested drug. In this case, the 
enrollee has not tried and failed the required drugs. However, step therapy may only be applied to new 
prescriptions or administrations of Part B drugs for enrollees that are not actively receiving the affected 
medication. The provided documentation supports that the enrollee has been successfully treated on 2 separate 
occasions with Gel-One injections in March of 2022 and December of 2022. The enrollee noted good results 
with the prior Gel-One injections, and as a result, the provider elected to repeat the Gel-One injection of the 
right knee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have been met. Therefore, we decided that the Plan has to pre-approve 
treatment with Gel-One (J7326).  
 
  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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on April 13, 2023. 
 
You asked the Plan to pay for physical therapy. You say that you are appealing the claim payment denial. 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 
provided on April 13, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chest xray provided on October 04, 2022. 
 
You asked the Plan to pay for a chest xray. You say that this was medically necessary and 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 a chest xray provided on 
October 04, 2022.