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

We decided that the Plan does not have to pay for a neuromuscular junction test (95937-26) performed on 
February 12, 2020. 
 
You asked the Plan to pay for a neuromuscular junction test. You say that a neuromuscular junction test was 
performed on February 12, 2020. The Plan denied your request. The Plan says rules for coverage of procedure 
code 95937-26 have not been met. 
 
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 looked at the file and Medicare Rules. Based on this information, we decided that Medicare rules for 
coverage of a neuromuscular junction test have not been met. Specifically, Train of Four is bundled with the 
intraoperative neuromonitoring of electromyography (EMG) or motor evoked potentials (MEP) and, therefore, 
is not separately reportable. Therefore, we decided that the Plan does not have to pay for a neuromuscular 
junction test (95937-26) performed on February 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Interfyl injection. 
 
You asked the Plan to pre-approve these services. You say that you have severe pain and are unable to put 
pressure on your right hip. The Plan denied your request. The Plan says Medicare coverage criteria are not met.  
 
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 services are not medically necessary. Our physician reviewer found the submitted records show that you 
had a right total hip replacement in 2018. You report severe pain that has worsened over the past year. You 
have failed treatment with surgery, therapy, pain medication, and injections. The use of Interfyl is considered 
experimental and investigational in nature and it is not widely used and generally accepted as treatment. The 
services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Interfyl injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for sedation services (99152) provided on January 28, 2020. 
 
You asked the Plan to pay for sedation services. You say that this is supported in the records. The Plan denied 
your request. The Plan says this code is not documented. 
 
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 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the records do not document 
the presence of an independent trained observer. Based on this information, we decided that Medicare rules for 
coverage of sedation services have not been met. Therefore, we decided that the Plan does not have to pay for 
sedation services (99152) provided on January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided by a participating 
provider on May 29, 2020. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you do not feel like you should pay this 
because you already paid a $45 copayment. 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 $45 
copayment for outpatient diagnostic tests/x-rays.  
 
You have been asked to pay a $45 copayment for an x-ray. When additional services are provided during an 
office visit, additional copayments are applied; therefore, the correct copayment has been applied to this x-ray. 
An x-ray falls within the outpatient diagnostic tests/x-rays 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 x-ray provided by a participating provider on May 29, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the pathology services provided on September 4, 2019. 
 
You asked the Plan to pay for the pathology services. The Plan denied your request. The Plan says that there is 
no authorization for the out-of-network service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. The rules also say that a contract plan provider is an agent of the plan. Services and referrals obtained 
from a plan provider are viewed as plan-approved unless notice is given that the services will not be covered. 
When a plan provider gives, or refers an enrollee for, a service that the enrollee reasonably believes is covered 
by the plan, the enrollee is held harmless and need not pay more than the plan-allowed cost-sharing for that 
service.  
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not identified the network status of the referring physician. 
Therefore, we decided that the Plan has to pay for the pathology services provided on September 4, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a straight knee joint (L2385) provided on April 15, 2020. 
 
You asked the Plan to pay for a straight knee joint. You say that this was medically necessary. The Plan denied 
your request. The Plan says there is not a valid order or proof of delivery for this item. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order or proof of delivery for the supplies provided in this case. 
The specific item at issue is included on the physician orders or delivery invoices that were submitted. The 
record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for a straight knee joint (L2385) provided on April 15, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
May 9, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network 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 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 out of network physician 
services provided to the enrollee on May 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for office visits and inpatient hospital services 
provided from January 6, 2020, through June 23, 2020. 
 
You asked the Plan to waive the copayments for the office visits, inpatient hospital services, and emergency 
services. You say that you were advised during the enrollment process that there would be no cost sharing if 
you used network providers. The Plan denied your request. The Plan says you were charged these cost sharing 
amounts correctly and there is nothing in the records showing that you were advised that all in-network 
services would have no cost sharing. 
 
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 for each in-network specialist visit and a $300 copayment per day for days 1-7 for inpatient hospital 
services.  
 
You have been asked to pay a $35 copayment for each in-network specialist visit you had from January 6, 
2020, through June 23, 2020. In addition, you have been asked to pay $600 for the inpatient hospital stay you 
had from March 9, 2020, through March 11, 2020 (a total of two days, $300 x 2=$600). 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 copayments for office visits and inpatient hospital services provided from January 6, 
2020, through June 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on April 2, 2020. 
 
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says non-
emergent services rendered by non-participating providers in non-participating facilities require prior 
authorization. 
 
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 
psychotherapy services. 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 psychotherapy services provided on April 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the MRI of the abdomen (74183) provided 
on May 4, 2020. 
 
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 each Medicare covered advanced radiology service.  
 
You have been asked to pay a $150 copayment for the advanced radiology service provided. 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 adjust the copayment for the MRI of the abdomen (74183) provided on May 4, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for ambulance transport provide to the enrollee on April 9, 2020. 
 
You asked the Plan to pay for ambulance transport. You say that this transport was medically necessary. The 
Plan denied your request. The Plan says that Medicare coverage criteria are not met. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance transport. Our reviewer says that 
ambulance transport was medically necessary.  Our physician reviewer found the enrollee was chronically ill 
with acute illness. The enrollee is hemiplegic and could not self-transport. Medicare coverage criteria were 
met.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ambulance transport have been met. Therefore, we decided that the Plan has 
to pay for ambulance transport provide to the enrollee on April 9, 2020.  
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist services rendered from 
January 7, 2020 to May 26, 2020. 
 
You asked the Plan to waive the copayments for these services. You say that you are not happy with the 
services provided. The Plan denied your request. The Plan says the copayments were 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $45 copayment for in-network Medicare-covered vision services at a specialist's office.  
 
Review of the file shows that the enrollee received vision care services at a specialist's office for five dates of 
service from January 7, 2020 to May 26, 2020. The enrollee has been asked to pay a $45 copayment per date of 
service for these services, for a total of $225. These services fall within the in-network Medicare-covered 
vision services at a specialist's office 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 the specialist services rendered from January 7, 2020 to May 26, 2020.  
 
Your complaint about the provider 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 pay for chiropractic services not related to manual manipulation 
from February 25, 2020, to March 24, 2020. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says the Plan and Medicare only covers services by a chiropractor that are 
related to manual manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not 
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic 
services not related to manual manipulation from February 25, 2020, to March 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the new outpatient office visit (99204), administration of 
patient focused health risk assessment (96160), tobacco counseling (99406) and preventative medicine 
counseling (99401) provided on December 19, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for new outpatient office visit, administration of patient focused health risk 
assessment, tobacco counseling and preventative medicine counseling. You say that the services rendered were 
medically necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-
emergent services rendered by an out-of-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 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 new outpatient office visit (99204), 
administration of patient focused health risk assessment (96160), tobacco counseling (99406) and preventative 
medicine counseling (99401) provided on December 19, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation, intraoral x-ray and palliative 
treatment provided on April 14, 2020. 
 
You asked the Plan to pay for the limited oral evaluation, intraoral x-ray and palliative treatment. You say that 
the treatment was an emergency procedure. You say that this should be covered because your other procedures 
were covered. The Plan denied your request. The Plan says the limited oral evaluation has exceeded frequency 
limitations and the x-ray and palliative treatment are not covered benefits. 
 
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, you also have a maximum benefit of 
one oral examination per calendar year. The Plan paid for a limited oral evaluation provided on January 13, 
2020, which exhausted your benefit. The intraoral x-ray and palliative treatment are not covered benefits. 
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation, intraoral x-ray and 
palliative treatment provided on April 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound of the heart you had on May 
6, 2020. 
 
You asked the Plan to waive the copayment for the ultrasound of the heart. You say that you do not recall 
having to pay this much when you had the procedure in the past.  You say that if you had known it would cost 
$160, you would not have had the test. 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 $160 
copayment for radiological diagnostic procedures performed in a physician's office or at a free-standing 
facility.  
 
You have been asked to pay a $160 copayment for the ultrasound of the heart. The ultrasound of the heart falls 
within the radiological diagnostic procedures 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 ultrasound of the heart you had on May 6, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health care services (S9122) provided January 13, 
2020 to February 4, 2020. 
 
You asked the Plan to pay for the home health care services. You say that you feel that you were misinformed 
of how the plan covers the home health care benefit because you were never informed a prior authorization was 
necessary. The Plan denied your request. The Plan says the services are not reasonable and necessary as no 
medical records were provided for review, the provider is a non-participating provider and there is no prior 
authorization as required for the HHA services. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
The file shows that multiple attempts were made by the plan to obtain medical records from the provider to 
determine if Medicare coverage criteria has been met. The plan did not pre-approve the HHA services at issue. 
Therefore, we decided that the Plan does not have to pay for the home health care services (S9122) provided 
January 13, 2020 to February 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services you received 
from April 18, 2020, to April 23, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you thought that all 
of your hospitalizations would be treated as one admission.  You say that you are on a fixed income and cannot 
afford this copayment. 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 $325 
copayment per day for days 1-6 per admission for inpatient hospital care.  
 
You have been asked to pay a $325 copayment per day for days 1-6 for the inpatient hospital services. Your 
Evidence of Coverage clearly states that this copayment is owed per admission. 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 inpatient hospital services you received from April 18, 2020, to April 23, 2020.