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

 
We decided that the Plan does not have to pre-approve referral to a tertiary-level ear, nose, and throat (ENT) 
specialist. 
 
You asked the Plan to pre-approve these services. You say that you are very ill and getting worse. The Plan 
denied your request. The Plan says the tertiary level of care is not medically necessary. 
 
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 these services. Our reviewer says that 
the tertiary level of care is not medically necessary. Our physician reviewer found the submitted records show 
that you having ringing in the ears (tinnitus), increased sensitivity to sound (hyperacusis), and ear fullness. 
Your conditions can be managed by a non-tertiary ENT specialist, as these are conditions that are regularly 
treated by ENTs. The records do not support that it is reasonable and medically necessary for you to receive the 
tertiary level of 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve referral to a tertiary-level ear, nose, and throat (ENT) specialist.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for strapping provided on February 4, 2020. 
 
You asked the Plan to waive the copayment for strapping. You say that you disagree with the fact that the 
service is considered an outpatient surgical procedure. 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 $100 
copayment for surgery services provided during a specialist's office visit.  
 
You received strapping on February 4, 2020. Strapping is considered a surgical procedure. Therefore, you are 
responsible to pay the $100 copayment.  
 
You have been asked to pay a $100 copayment for strapping. Strapping falls within the outpatient surgery, 
including services provided at hospital 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 strapping provided on February 4, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room provided on April 6, 
2020. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that your emergency room 
visit was related to your COVID diagnosis and you should not be responsible for the copayment. The Plan 
denied your request. The Plan says you have been charged the correct cost sharing 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 $120 
copayment per visit for Medicare-covered emergency care.  
 
You have been asked to pay a $120 copayment for the emergency room visit. The emergency room visit falls 
within the "Emergency 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 copayment for the 
emergency room provided on April 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiological diagnostic services provided 
by a participating provider on January 17, 2020. 
 
You asked the Plan to waive the copayment for radiological diagnostic services. You say that you do not agree 
with these copayments. The Plan denied your request. The Plan says the correct copayment has been 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 $125 
copayment for outpatient diagnostic tests/radiological diagnostic services.  
 
You have been asked to pay a $125 copayment for radiological diagnostic services. The total amount you are 
being asked to pay is $250 ($125 x 2 radiological diagnostic tests = $250). Radiological diagnostic services fall 
within the outpatient diagnostic tests/radiological diagnostic 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 radiological diagnostic services provided by a participating provider 
on January 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a ceftriaxone sodium injection (J0696) and a garamycin, 
gentamicin injection (J1580) provided on December 4, 2019. 
 
You asked the Plan to pay for the injections. 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 J0696 is injection, ceftriaxone sodium, per 250 mg. 
 
The CPT Code Manual definition of code J1580 is  Injection, garamycin, gentamicin, up to 80 mg. 
 
We find that CPT code J0696 and J1580 is not supported in the record. Specifically, the documentation does 
not show that these injections were rendered on the billed date of service. Based on this information, we 
decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the 
Plan does not have to pay for a ceftriaxone sodium injection (J0696) and a garamycin, gentamicin injection 
(J1580) provided on December 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a 
participating provider on March 12, 2020. 
 
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you are in dire 
financial shape due to Covid-19. You say that you cannot afford this. The Plan denied your request. The Plan 
says the correct coinsurance has been 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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The 
total allowed amount is $1,119.64. The total amount you are being asked to pay is $223.93 ($1,119.64 x 20% = 
$223.93). Durable medical equipment falls within the durable medical equipment 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 durable medical equipment provided by a participating provider on 
March 12, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on February 3, 2020. 
 
You asked the Plan to pay for lab test. You say that this testing was ordered to determine the optimal treatment 
pathway for the enrollee. The Plan denied your request. The Plan says the denial of payment for this service is 
correct, because the enrollee was enrolled in hospice on this date of service and therefore the Plan is not 
responsible for payment of this claim. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for laboratory testing provided on February 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on April 18, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on April 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the biopsy provided on March 11, 2020. 
 
You asked the Plan to waive the copayment for the biopsy. You say that you are retired and on a limited 
income and the $400 is a high copayment. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing 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 $400 
copayment for outpatient hospital facility.  
 
You have been asked to pay a $400 copayment for the biopsy. The biopsy falls within the outpatient hospital 
facility 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 the biopsy provided 
on March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on July 6, 2018. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you keep receiving bills for the 
service. 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 $30 
copayment for specialist visits.  
 
You have been asked to pay a $30 copayment for a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctor's office visits 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 specialist visit provided on July 6, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for wound debridement provided from 
February 12, 2020 to March 18, 2020. 
 
You asked the Plan to waive the copayments for wound debridement. You say that you feel that the charges are 
too high. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 
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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $275 copayment for outpatient surgery and other medical services provided at hospital outpatient 
facilities and ambulatory surgical centers.  
 
The enrollee received wound debridement on February 12, 2020 and February 19, 2020. Therefore, the enrollee 
is responsible to pay a $275 copayment per each visit.  
 
The enrollee received wound debridement on February 26, 2020 and March 18, 2020. Therefore, the enrollee is 
responsible to pay the allowed amount of $175.39, which is less than the $275 copayment per each visit. 
 
The total amount the enrollee owes is: $850.78.  
 
The enrollee has been asked to pay the total amount of $850.78 for wound debridement. Wound debridement 
falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers benefit category.  
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This 
cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayments for wound debridement provided from February 
12, 2020 to March 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant at surgery services provided on November 7, 2019. 
 
You asked the Plan to pay for the assistant at surgery services. You say that the medical records provided 
support the services in dispute. The Plan denied your request. The Plan says the billed services were not 
supported. The Plan says that the services of a surgical technician assisting at surgery are included in the 
reimbursement to the facility and not separately reimbursable. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay for assistant at surgery 
services performed by a person who bears any title or license other than those listed. 
 
We looked at the file and Medicare rules. The records show that the assistant at surgery services in dispute 
were performed by a certified surgical first assistant (CSFA). Based on this information, we decided that 
Medicare rules for coverage of the assistant at surgery services have not been met. Therefore, we decided that 
the Plan does not have to pay for assistant at surgery services provided on November 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 6, 2019. 
 
You asked the Plan to pay for the services provided. You say that you did not receive proper notice of the 
enrollee's benefit determination. The Plan denied your request. The Plan says the timely filing limit was 
exceeded. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services provided was not filed until February 12, 2020. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the medical services provided on February 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Life Alert device (E1399). 
 
You asked the Plan to pre-approve the Life Alert device. You say that you suffer from severe vertigo and lose 
your balance and falls a lot and feel that Life alert will be very helpful. The Plan denied your request. The Plan 
says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the Life Alert device (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient surgery for percutaneous implantation, 
neurostimulator electrodes; sacral nerve w/transforaminal placement provided on January 14, 2020. 
 
You asked the Plan to pay for the outpatient surgery. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented.   
 
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 
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 outpatient surgery for percutaneous implantation, 
neurostimulator electrodes; sacral nerve w/transforaminal placement provided on January 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on February 
18, 2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges 
because you were told that you would not owe anything. 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 $325 
copayment for ambulance services.  
 
You have been asked to pay a $325 copayment for ambulance services. Ambulance services fall within the 
ambulance 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 ambulance services 
provided on February 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from August 8, 
2019 to August 12, 2019. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the 
charges because you already paid the 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 $425 
copayment for inpatient hospital care, per admission.  
 
You have been asked to pay a $425 copayment for an inpatient hospital stay. An inpatient hospital stay falls 
within the inpatient hospital care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
an inpatient hospital stay from August 8, 2019 to August 12, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on May 1, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a 
physician. 
 
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the drug testing rendered on May 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the destruction by neurolytic agent services coded 64624 provided on February 12, 2020.
You asked the Plan to pay for the destruction by neurolytic agent services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 64624 is 2. You billed 3 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the destruction by neurolytic agent services have not been met. Therefore, we decided that the Plan does not have to pay for the destruction by neurolytic agent services coded 64624 provided on February 12, 2020.