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

 
We decided that the Plan does not have to pay for the PET/CT scan (78815-26, PS) provided on May 22, 2020. 
 
You asked the Plan to pay for the PET CT scan. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the PET/CT scan was not billed with an appropriate 
diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that the number of PET scans that are allowed are 
based on the exact diagnosis for which they are provided. As such, Medicare has a list of appropriate diagnosis 
codes that may be used.  
 
We looked at the file and Medicare rules. The reported diagnosis codes of C54.9 and R19.00 are not listed as 
appropriate diagnosis codes. Based on this information, we decided that Medicare rules for coverage of the 
PET CT scan have not been met. Therefore, we decided that the Plan does not have to pay for the PET/CT scan 
(78815-26, PS) provided on May 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided from May 17, 2020 
to May 18, 2020. 
 
You asked the Plan to pay for the inpatient hospital services. 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. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. We find that the file does not support the inpatient services billed 
from May 17, 2020 to May 18, 2020. Specifically, after attempts made by the Plan to obtain medical records 
for these dates of service, these records were not provided to the Plan for review. Therefore, we decided that 
the Plan does not have to pay for the inpatient hospital services provided from May 17, 2020 to May 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services from April 16, 2020, through 
April 17, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that the medics were following the COVID 
executive order for treatment in place. The Plan denied your request. The Plan says these services are not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 16, 2020 to April 17, 2020. The 
ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays 
for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services 
from April 16, 2020, through April 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you had surgery and need this chair to shower 
safely. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgical services received on 
January 15, 2020. 
 
You asked the Plan to waive the copayment for outpatient surgical services. You say that you should be 
charged a $75 copayment. The Plan denied your request. The Plan says the correct copayment was applied. 
 
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 $250 
copayment for each visit to a hospital outpatient surgical department.  
 
You have been asked to pay a $250 copayment for outpatient surgical services. Outpatient surgical services 
performed at an outpatient hospital fall 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 outpatient surgical services received on January 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services you received on 
March 24, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you have a zero copay 
plan, so you shouldn't have to pay anything for this service. The Plan denied your request. The Plan says you 
do not have a zero copay plan.  The Plan says that 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 $250 
copayment for ambulance services.  
 
You have been asked to pay a $250 copayment for the ambulance services.  You are not currently enrolled in a 
zero copayment plan. 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 ambulance services you 
received on March 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the ophthalmology services provided on 
May 18, 2020. 
 
You asked the Plan to waive the cost share for the ophthalmology services. You say that you feel you should 
not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan 
denied your request. The Plan says you received medical vision services on the date of service at issue in this 
appeal. The Plan says the correct copayment has applied per your contract with the Plan. 
 
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 $35 
copayment per visit to an ophthalmologist or optometrist for Medicare-covered vision care.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an 
ophthalmologist medical exam on May 18, 2020. You have been asked to pay a $35 copayment for the 
ophthalmology services. The ophthalmology services fall within the Vision 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. Therefore, we decided that the Plan 
does not have to waive the cost share for the ophthalmology services provided on May 18, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit services provided to the enrollee. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says upcoding from this physician group is well known. 
 
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 99350 is "home visit by a physician or advanced 
practitioner such as a physician assistant (PA) or nurse practitioner (NP)." 
 
We find that CPT code 99350 is not supported in the medical record. Specifically, this code requires a specific 
type of advanced practitioner. The rendering practitioner is a RN, which is not covered for this code. 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 home visit services provided to the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan you 
had on June 12, 2020. 
 
You asked the Plan to waive the copayment for the CT scan. You say that this is too high a copayment for such 
a common service. The Plan denied your request. The Plan says you were charged this copayment correctly.  
The plan says that because the allowed amount for this service is less than your copayment responsibility, you 
are responsible for the full amount ($227.56). 
 
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 $295 
copayment for diagnostic radiology services, including CT scans.  
 
You have been asked to pay the full amount of $227.56 because it less than the applicable $295 copayment for 
CT scans. 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 computed tomography (CT) 
scan you had on June 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses provided on June 30, 2020. 
 
You asked the Plan to pay for the eyeglasses. The Plan denied your request. The Plan says services were 
provided by an out-of-network provider and no authorization was obtained. 
 
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 did not pre-approve 
coverage for the eyeglasses. We found no exception that would require the Plan to pay for the eyeglasses. 
Therefore, we decided that the Plan does not have to pay for eyeglasses provided on June 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for fluoroscopic guidance for needle placement 
provided. 
 
You asked the Plan to waive the copayment for fluoroscopic guidance for needle placement. You say that you 
disagree with the charges because you expected to only pay a $25 copayment. 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 a $150 
copayment for diagnostic radiology.  
 
You have been asked to pay the allowed amount of $110.14, which is less than the $150 copayment for 
fluoroscopic guidance for needle placement. Fluoroscopic guidance for needle placement 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 fluoroscopic guidance for needle placement provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a lumbar-sacral brace (L0637) received on 
November 18, 2019. 
 
You asked the Plan to waive the coinsurance for a lumbar-sacral brace. You say that the Plan initially informed 
you that you had a $0 copayment for this item. The Plan denied your request. The Plan says the correct 
copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare-covered durable medical equipment.  
 
You have been asked to pay $267.45, or 20% coinsurance of the Plan-allowed amount of $1,337.25, for a 
lumbar-sacral brace. A lumbar-sacral brace falls within the "Durable medical equipment (DME) and related 
supplies" benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a lumbar-sacral brace 
(L0637) received on November 18, 2019.  
 
Your complaint about receiving erroneous or misleading cost-sharing information from the Plan is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sacroiliac (SI) Joint Injections (27096). 
 
You asked the Plan to pre-approve the joint injections. You say that the injections are medically necessary. The 
Plan denied your request. The Plan says records do not support the efficacy of the previous injections. 
 
The Plan follows Medicare rules. Medicare rules say that SI Joint injections are covered when medically 
necessary. 
 
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 joint injections. Our reviewer says 
that the injections are not medically necessary. Our physician reviewer found there is no detail of the degree 
and duration of the pain relief from the prior SI joint injection. This lack of documentation does not meet the 
required criteria. 
 
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 joint injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Sacroiliac (SI) Joint Injections (27096).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for 3 Euflexxa injections (J7323) received on 
March 4, March 11, and March 19, 2020, and a Triamcinolone injection (J3304) received on May 6, 2020. 
 
You asked the Plan to waive the coinsurance for 3 Euflexxa injections and a Triamcinolone injection. You say 
that the hospital is charging you incorrectly. The Plan denied your request. The Plan says the correct 
coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare-covered Part B Chemotherapy drugs and other Part B drugs.  
 
You have been asked to pay $56.59, or 20% coinsurance of the Plan-allowed amount of $282.94, for each of 3 
Euflexxa injections, and $119.26, or 20% coinsurance of the Plan-allowed amount of $596.29, for a 
Triamcinolone injection. Euflexxa injections and a Triamcinolone injection fall 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 coinsurance for 3 Euflexxa 
injections (J7323) received on March 4, March 11, and March 19, 2020, and a Triamcinolone injection (J3304) 
received on May 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammogram with digital 
breast tomosynthesis you had on July 16, 2020. 
 
You asked the Plan to waive the copayment for the diagnostic mammogram. You say that you had cancer and 
have never paid for a screening exam. The Plan denied your request. The Plan says this was not a screening 
exam, so you were charged the 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 $45 
copayment for routine radiology services.  
 
Records show that this mammogram was ordered as a result of your breast cancer diagnosis- it was not ordered 
as a screening exam.  That is why cost sharing applies here. You have been asked to pay a $45 copayment for 
the diagnostic mammogram. The diagnostic mammogram falls within the routine radiology services 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 diagnostic mammogram with digital breast 
tomosynthesis you had on July 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the hyaluronan injection and arthrocentesis 
provided on March 24, 2020. 
 
You asked the Plan to waive the cost share for the hyaluronan injection and arthrocentesis. You say that the 
injection did not last, and you did not have any relief. You say that you shouldn't have to pay for an injection 
that didn't work. The Plan denied your request. The Plan says the cost share 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 20% 
coinsurance for Medicare Part B prescription drugs and a $20 copayment per visit to a specialist.  
 
You have been asked to pay a total of $470 for the hyaluronan injection and arthrocentesis.  
 
Service Allowed          Amount     Standard Cost     Member Liability 
Hyaluronan Injection   $2,250       20%                   $450 
Arthrocentesis           $52.48       $20                     $20 
TOTAL:   $470 
 
The hyaluronan injection falls within the "Medicare Part B prescription drugs" benefit category. The 
arthrocentesis falls within the 'Physician/Practitioner services, including doctor's office visits' benefit 
category. The records show that you received the hyaluronan injection and arthrocentesis. 
 
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 hyaluronan injection and arthrocentesis provided on 
March 24, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diagnostic nuclear medicine procedures to be provided 
by the out-of-network provider. 
 
You asked the Plan to pre-approve the diagnostic nuclear medicine procedures. The Plan denied your request. 
The Plan says there are in-network providers available to perform this service. The Plan requires the enrollee to 
use in-network providers when they are available. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve diagnostic 
nuclear medicine procedures to be provided by the out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT chest scan (71250) provided on February 4, 2020, by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the CT chest scan. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider; therefore, payment has been correctly denied. 
 
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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the CT chest scan (71250) provided on February 
4, 2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit provided by an 
OON provider. 
 
You asked the Plan to pay for the outpatient office visit. The Plan denied your request. The Plan says the 
service was rendered by a non-contracted provider. The Plan also says that you self-referred for care. 
 
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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the outpatient office visit provided on
 by an OON provider.