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

We decided that the Plan does not have to waive the deductible charged for the ultrasound you had on July 1, 
2020. 
 
You asked the Plan to waive the deductible charged for the ultrasound. You say that you didn't ask for this 
procedure--your doctor told you to get it.  You said that you don't feel you should owe this amount. The Plan 
denied your request. The Plan says you were assessed this deductible 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 that must be met before the Plan will pay for your 
care.  
 
You had not yet met your deductible at the time you had this ultrasound. The Plan has followed Medicare rules 
by clearly disclosing in the contract that there is a $750 deductible. This cost sharing is a contractual obligation 
that had not been met at the time the ultrasound was received on July 1, 2020. This deductible applies 
regardless of the reason for this ultrasound. Therefore, we decided that the Plan does not have to waive the 
deductible charged for the ultrasound you had on July 1, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services 
provided from April 9, 2020, to May 8, 2020. 
 
You asked the Plan to waive the copayment for the SNF services. You say that this copayment should be 
waived because you had COVID-19. The Plan denied your request. The Plan says you were charged this 
copayment 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 $0 
copayment for days 1-20 and a $178 copayment per day for days 21-100 for skilled nursing facility care.  
 
Records show that you were in the SNF for a total of 29 days.  You were charged a $0 copayment for days 1-
20. For the remaining 9 days, you were charged a $178 copayment per day for a total of $1602. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. There is no provision for 
a waiver of this amount in your contract if the SNF stay was needed as a result of COVID-19. 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 skilled nursing facility (SNF) services provided from April 9, 2020, 
to May 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion services (S9348) provided January 4, 2020 to 
January 11, 2020. 
 
You asked the Plan to pay for the home infusion services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the CPT code billed cannot be paid. 
 
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 CPT code S9348 is not supported in the medical record. Specifically, this CPT code is marked 
with a status of "I" and is invalid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of the home infusion services have not been met. Therefore, we decided that the Plan does 
not have to pay for home infusion services (S9348) provided January 4, 2020 to January 11, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for urgent care services provided by a non-participating 
provider on October 8, 2019. 
 
You asked the Plan to waive the copayment for urgent care services. You say that you went to the ER within 24 
hours. You say that you should have this copayment waived. The Plan denied your request. The Plan says that 
the correct copayment has been applied. 
 
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 enrollees must pay a $0 copayment for urgently needed services.  
 
The Plan says you must pay a $25 copayment for urgent care services. Based on the Plan contract, however, 
you cannot be asked to pay more than a $0 copayment for urgent care services. Therefore, we decided that the 
Plan has to waive the copayment for urgent care services provided by a non-participating provider on October 
8, 2019.  
 
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health services. 
 
You asked the Plan to pre-approve home health services. You say that the home health services are medically 
necessary. The Plan denied your request. The Plan says there is no longer a need for skilled home health 
services. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the additional home health visits are not medically necessary. Our physician reviewer found there was 
no report in recent notes suggesting an ongoing need for instruction and supervision of medication management 
or disease management by a skilled nurse. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional home health services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Superion interspinous spacer for the enrollee. 
 
You asked the Plan to pre-approve the spacer. You say that this is medically necessary. The Plan denied your 
request. The Plan says a review of the current medical literature indicates that this service is considered 
experimental and 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 pre-approve the spacer. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the spacer is experimental. More research is needed to show safety and efficacy. 
 
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 spacer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Superion interspinous spacer for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the intermittent compression device. You say that the claim should be paid. 
The Plan denied your request. The Plan says you have not provided reasoning for why this is emergent, urgent, 
or why you cannot obtain a pneumatic compression device from 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 
the medical services to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a CT scan and does not have to waive the 
copayment for carpal tunnel surgery provided from June 12, 2020, to June 19, 2020. 
 
You asked the Plan to waive the coinsurance for a CT scan and to waive the copayment for carpal tunnel 
surgery. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims 
were processed correctly and you are being charged the correct amount. 
 
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 diagnostic radiology services up to a maximum of $75. Your contract with the Plan also clearly 
says that you must pay a $75 copayment for outpatient surgery, including services provided at hospital 
outpatient facilities and ambulatory surgical centers. 
 
You received a CT scan on June 12, 2020. The allowed amount is $213.58 and 20% of that is $42.72.  
 
You received carpal tunnel surgery on June 19, 2020. Therefore, you are responsible to pay the $75 copayment.  
 
The total amount you owe is: $117.72.   
 
 
You have been asked to pay the total amount of $117.72 for a CT scan and carpal tunnel surgery. A CT scan 
falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. Carpal tunnel 
surgery 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 coinsurance for a CT scan 
and does not have to waive the copayment for carpal tunnel surgery provided from June 12, 2020, to June 19, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with a general 
surgeon on May 7, 2020. 
 
You asked the Plan to waive the copayment for the office visit with a general surgeon. You say that you 
received a card from your plan stating that certain copayments would be waived from May 1, 2020, to 
December 31, 2020.  You believe that this general surgery office visit copayment should be waived due to this 
card. The Plan denied your request. The Plan says you were charged this amount 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 $25 
copayment for office visits with a specialist.  
 
You have been asked to pay a $25 copayment for the office visit with a general surgeon. Records show that the 
copayment waiver card you received clearly states that only copayments for primary care visits, outpatient 
behavioral health visits, and telehealth visits are being waived.  There is nothing on the card to indicate that 
specialist visits or surgery service copayments will be waived. The visit you had with a general surgeon is a 
specialist visit. 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 visit you had with a general 
surgeon on May 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a screening pelvic exam received on March 26, 2020. 
 
You asked the Plan to pay for the services. You say that this should be covered once a year. The Plan denied 
your request. The Plan says the benefit has been exhausted in this case. 
 
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 screening pelvic exams 
are covered once every 24 months.  
 
The same service was previously received on January 19, 2019. This was less than two years before the date of 
service. Therefore, we decided that the Plan does not have to pay for a screening pelvic exam received on 
March 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a 10mg triamcinolone acetonide injection (J3301) provided 
on January 15, 2020. 
 
You asked the Plan to pay for the injection. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the documentation submitted does not support the 
service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code J3301 is injection, triamcinolone acetonide, not otherwise 
specified, 10 mg. 
 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the injection. Our reviewer says that CPT code J3301 does 
not meet criteria for billing or reimbursement consideration. Our reviewer found the procedure note documents 
"(LEFT) Subacromial bursa was with 40 mg Triamcinolone Diacetate." There is a more appropriate code to 
report for this injection. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pay for a 10mg triamcinolone acetonide injection (J3301) provided on January 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation and setup of portable x-ray equipment and 
personnel on September 26, 2019. 
 
You asked the Plan to pay for the transportation (R0070) and setup (Q0092) of portable x-ray equipment and 
personnel to the skilled nursing facility. You say that the Plan should pay this claim. The Plan denied your 
request. The Plan says in this place of service the claim is not separately reimbursable. 
 
The Plan must follow Medicare rules. Medicare rules say that the technical component of radiology services in 
a SNF, during a covered stay, are not separately payable. 
 
We find that CPT code R0070,Q0092 is not supported in the medical record. Specifically, the transportation 
and set up costs are subject to consolidated billing. Based on this information, we decided that Medicare rules 
for coverage of the transportation (R0070) and setup (Q0092) of portable x-ray equipment and personnel to the 
 skilled nursing facility have not been met. Therefore, we decided that the Plan does not have to pay for the 
transportation and setup of portable x-ray equipment and personnel on September 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve L3-5 medial branch block (64493 x2 and 64494 x2). 
 
You asked the Plan to pre-approve medial branch block. You say that the records provided should support the 
necessity of the service in dispute. The Plan denied your request. The Plan says the documentation received 
does not support the and medical necessity of this service. 
 
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 medial branch block. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the prescriber provided an MRI report dated July 3, 2018, and an office note with 
physical exam dated March 23, 2017. Procedure notes dated April 19, 2017, and May 17, 2017, were provided, 
as well, an office visit note dated November 18, 2019. The office note dated November 18, 2019, does not have 
a physical exam documented. The section where the physical exam should be recorded is blank. The area 
where the Review of Systems should be recorded is mostly blank. The note states that the enrollee has 
radiculopathy and low back pain. There is no current patient assessment or physical exam to identify the type, 
severity, or location of the enrollee's pain. There is no current assessment of the enrollee's functional 
limitations or impairments. The enrollee does not meet the criteria for coverage. Therefore, the requested 
injections are not medically reasonable and necessary to treat the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of medial branch block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve L3-5 medial branch block (64493 x2 and 64494 x2).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on 
May 31, 2020. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you believe you were admitted to the 
hospital, so this copayment should be waived. The Plan denied your request. The Plan says you were not 
admitted to the hospital.  The records and claims from the hospital show that you were kept in observation.  
Because you were not formally admitted, the copayment was applied 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 $110 
copayment for emergency room visits.  
 
You have been asked to pay a $110 copayment for the ER visit. Your Evidence of Coverage clearly states that 
if you are held in observation, this $110 copayment still applies.  The records show that you were kept in 
observation.  You were not formally admitted as an inpatient. 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 emergency room (ER) visit you had on May 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional intraoral x-ray provided on June 26, 2020. 
 
You asked the Plan to pay for the additional intraoral x-ray. You say that you were not informed you would be 
billed that amount. The Plan denied your request. The Plan says the frequency limit has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
additional intraoral x-ray provided on June 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lyrica (J8499). 
 
You asked the Plan to pre-approve Lyrica. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee has a medical only policy which does not include Part D prescription 
coverage, therefore the criteria for self-administered drug coverage has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lyrica (J8499).  
 
Benefits for Lyrica may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
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 you would like reconsideration because the IRF 
admission is medically necessary. The Plan denied your request. The Plan says the member does not meet 
Medicare coverage criteria for IRF admission. 
 
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. Our 
physician reviewer found the documentation does not support that the complexity of the enrollee's nursing, 
medical and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The documentation does not support that this enrollee requires treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. There is not a reasonable expectation that this patient 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.