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

 
We decided that the Plan does not have to waive the cost share for the Part B drug provided on February 26, 
2020. 
 
You asked the Plan to waive the cost share for the services provided. You say that you were not notified that 
you would have any other copay. The Plan denied your request. The Plan says there is no contract provision for 
the waiver of this cost share. 
 
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 Medicare Part B prescription drug.  
 
You have been asked to pay a 20% coinsurance for the services provided. The service falls within the Medicare 
Part B prescription drug 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 Part B 
drug provided on February 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 600 units of Botox. 
 
You asked the Plan to pre-approve the requested dosage. You say that the enrollee has been receiving 600 units 
since 2013. The Plan denied your request. The Plan says more than 400 units per 3-month period is not 
covered. 
 
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 the requested dosage. Our physician 
reviewer found that the enrollee has dystonia, and has a functioning deep brain stimulator. The physician has 
been administering a total of 535 units over 3 body areas, good effect. The number of units administered 
exceeds the package insert recommended dosage. A 400-unit limit can be achieved by slightly decreasing the 
dosages administered. The excess is not medically reasonable or 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 the requested dosage have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 600 units of Botox.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for noncontact normothermic wound therapy (97610) provided 
on March 20, 2020. 
 
You asked the Plan to pay for the wound therapy. You say that you would like reconsideration because this 
service is medically necessary. The Plan denied your request. The Plan says the service does not meet criteria 
for coverage. 
 
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 the wound therapy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this procedure is considered investigational and is not covered. 
 
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 wound therapy have not been met. Therefore, we decided that the Plan does 
not have to pay for noncontact normothermic wound therapy (97610) provided on March 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve trigger point injections. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that trigger point injections are covered when specific 
criteria 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee presents with complaints of 
increased bilateral hand and wrist pain. He has been diagnosed with carpal tunnel syndrome. There is no 
evidence that the enrollee is diagnosed with myofascial pain syndrome. An upper extremity physical exam 
consistent with Medicare criteria is not documented. The trigger point injections do not meet the criteria for 
coverage and are not reasonable or medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve trigger point injections.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that ongoing skilled services can be provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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. The 
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to 
require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care 
needs can be met at a lower level of care. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for IRF care. 
 
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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided June 17, 2020 to 
June 24, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee presented to the emergency department (ED) with dementia and weight 
loss.  While the enrollee spent two midnights in the hospital, at the time of admission, it was not reasonable to 
expect that two midnights of inpatient level care would be medically necessary. The enrollee was evaluated in 
the ED for progressive dementia.  No acute life/limb threatening conditions, warranting inpatient level care, 
were identified. The enrollee could have been safely monitored on observation status or further evaluated as an 
outpatient. The enrollee went on to receive part of an outpatient work-up for suspected cancer. The enrollee 
was also put on isolation for a positive CoViD screening test, but does not appear to have been actively treated 
for this infection. There is no documentation of a need for, or provision of, inpatient level care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided June 17, 2020 to June 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for thirty units of infusion supplies (A4222) provided from 
February 2, 2020 to March 2, 2020. 
 
You asked the Plan to pay for infusion supplies. You say that this should be covered. The Plan denied your 
request. The Plan says this code is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code A4222 is infusion supplies for external drug infusion 
pump, per cassette or bag (list drugs separately) . 
 
We find that 30 units of CPT code A4222 is not supported in the medical record. Specifically, there is no proof 
of delivery or other documentation showing that 30 cassettes or bags of infusion supplies were delivered or 
dispensed during the dates of service billed. Based on this information, we decided that Medicare rules for 
coverage of infusion supplies have not been met. Therefore, we decided that the Plan does not have to pay for 
thirty units of infusion supplies (A4222) provided from February 2, 2020 to March 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider on March 11, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide 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 medical services provided to you by an out-of-network provider on March 
11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visits and injections provided on 
January 28, 2020 and February 18, 2020. 
 
You asked the Plan to waive the copayment for the office visits and injections. You say that you paid your 
copayment at the office so you should not have a charge of $12.52. The Plan denied your request. The Plan 
says you have a $30 copayment for a podiatrist office visit and a 20% coinsurance for the injection. 
 
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 $30 
physician specialist copayment, and 20% coinsurance for Part B drugs. 
 
You have been asked to pay a $30 specialist copayment, and 20% coinsurance for the injections. The record 
shows you only paid a $20 copayment on January 28, 2020. The Part B drug coinsurance for the injections is 
$2.52. 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 office visits and injections provided on 
January 28, 2020 and February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on April 30, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 has network providers 
available who can provide 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 medical services provided to the enrollee by an out-of-network provider 
on April 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99285) provided on April 
13, 2020. 
 
You asked the Plan to pay for the emergency department visit. You say that you would like reconsideration 
because the member was seen multiple times on the same date of service. The Plan denied your request. The 
Plan says the same CPT code has been processed on a separate claim for a provider within the same specialty 
group. 
 
The Plan must follow Medicare rules. Medicare rules say that physicians in the same group practice who are in 
the same specialty must bill and be paid as though they were a single physician. 
 
We find that CPT code 99285 is not supported in the record. Specifically, the record indicates that CPT code 
99285 has been processed and paid to a different provider in the same group with the same specialty on the 
billed date of service. Based on this information, we decided that Medicare rules for coverage of the emergency 
department visit have not been met. Therefore, we decided that the Plan does not have to pay for the emergency 
department visit (99285) provided on April 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on May 13, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network 
services are 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide 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 medical services provided to the enrollee by an out-of-network provider 
on May 13, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy with biopsy and specimen 
removal provided on June 11, 2020. 
 
You asked the Plan to waive the copayment for colonoscopy. You say that nobody told you that this 
colonoscopy would have cost-sharing and your prior colonoscopy did not cost you anything. The Plan denied 
your request. The Plan says the copayment amount you are being charged is correct. 
 
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 $250 
copayment for colonoscopy with biopsy provided at an ambulatory surgical center. The record shows that 
biopsies were performed during this colonoscopy, therefore it is considered to be a surgical service with 
copayment and not a screening or preventive service. 
 
You have been asked to pay $250 copayment for colonoscopy. Colonoscopy falls within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 colonoscopy with biopsy and specimen 
removal provided on June 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve capsulotomy (66821). 
 
You asked the Plan to pre-approve the capsulotomy. You say that you would like reconsideration because you 
are not able to see well. The Plan denied your request. The Plan says glare testing may be indicated to establish 
medical necessity of this service based on the records provided. 
 
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 pre-approve the capsulotomy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found glare testing has not been done to validate your 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 the capsulotomy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve capsulotomy (66821).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy services provided from
September 20, 2019 through December 30, 2019 by an out-of-network provider.
You asked the Plan to waive the copayment for the physical therapy services. You say that Medicare used to
pay for your physical therapy in the past and you thought you were still on Medicare. The Plan denied your
request. The Plan says the claims were processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Per the above benefits and guidelines listed in your 2019 Evidence of Coverage, the plan has determined that
the total copayment of $2,371.87 was applied correctly to the therapy sessions you received between
September 20, 2019 to December 31, 2019.
For dates of service September 20, 2019, September 23, 2019, September 25, 2019, September 27, 2019 and
September 30, 2019:
For service 97112 (Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of
movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing
activities) the provider billed the plan in the amount of $50.00 and the allowed amount was $30.51. For out-of-network
physical therapy services you are responsible for a $75.00 copayment. Since the allowed amount is
less than the $75.00 copayment amount the plan only assessed a copayment amount of $30.51 this service.
For service 97116 (Therapeutic procedure, one or more areas, each 15 minutes; gait training (includes stair
climbing)) the provider billed the plan in the amount of $50.00 and the allowed amount is $26.90. For out-of-network
physical therapy services the you are responsible for $75.00 copayment. Since the plan previously
applied $30.51 toward the copayment, you had a remaining cost share of $44.49 ($75.00 - $30.51). As the
allowed amount was still lower than the remaining copayment amount of $44.49, you were only held liable for
the allowed amount of $26.90.
For service 97530 (Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to
improve functional performance), each 15 minutes) the provider billed the plan in the amount of $50.00 and the
allowed amount is $32.60. For out-of-network physical therapy services you are responsible for $75.00
copayment. Since the plan previously applied $57.41 toward the copayment, you had a remaining cost share of
$17.59 ($75.00 - $57.41). The plan applied the remaining copayment of $17.59 for this code. 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 physical therapy services provided from September 20, 2019
through December 30, 2019 by an out-of-network provider.