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

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on April 
28, 2020. 
 
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you disagree with the 
increase in 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 Medicare Part B prescription drugs.  
 
You received a Medicare Part B drug on April 28, 2020. The allowed amount is $1,752.52 and 20% of that is 
$350.50.  
 
You have been asked to pay the total coinsurance amount of $350.50 for a Medicare Part B drug. A Medicare 
Part B drug falls 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 a Medicare Part B drug provided on April 28, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the colonoscopy and biopsy (45380) provided on February 
12, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for colonoscopy. 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 colonoscopy and biopsy (45380) provided on 
February 12, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a trigger point injection provided on June 9, 
2020. 
 
You asked the Plan to waive the copayment for a trigger point injection. You say that you disagree with how 
the claims were processed and feel you should owe a lesser 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 $250 
copayment for outpatient surgery, including services provided at hospital outpatient facilities.  
 
You received a trigger point injection on June 9, 2020, at an outpatient hospital facility. A trigger point 
injection is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $250 
copayment.  
 
You have been asked to pay a $250 copayment for a trigger point injection. A trigger point injection falls 
within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for a trigger point injection 
provided on June 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies haven't proven that the device is helpful for treatment of your health 
problem. 
 
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 device. 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. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 20, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the comprehensive audiometry threshold evaluation and speech recognition. You 
say that you would like reconsideration because there should be a referral on file. The Plan denied your request. 
The Plan says the services rendered were not urgent, emergent or referred by a 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 medical services provided on May 20, 2020 by 
an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically 
necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested 
LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found 
Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not 
provide clinical services that are materially different than those of short-term acute care hospitals. The enrollee 
is receiving acute hospital care, and acute care services have not been denied. The documentation does not 
support that the enrollee in this case requires services at the LTACH that are not available at the acute care 
hospital where he is currently receiving care. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ophthalmology exam you had on June 
10, 2020. 
 
You asked the Plan to waive the copayment for the ophthalmology exam. You say that you believe this service 
should be covered in full because you are diabetic and the costs for all of your services are too expensive.  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 $45 
copayment for visits for services to diagnose or treat a disease or condition of the eye.  
 
You have been asked to pay a $45 copayment for the ophthalmology exam. The ophthalmology exam falls 
within the visits for services to diagnose or treat a disease or condition of the eye 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 ophthalmology exam you had on June 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the denosumab injection you received on 
June 23, 2020. 
 
You asked the Plan to waive the coinsurance for the denosumab injection. You say that you believe you should 
only have to pay a $50 copayment for each injection. The Plan denied your request. The Plan says you were 
charged this coinsurance 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 drugs.  
 
You have been asked to pay 20% coinsurance for the denosumab injection. The denosumab injection falls 
within the Medicare Part B 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 
the denosumab injection you received on June 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 Power Mobility Device (PMD) with 
accessories (E1007, E1028, E2300, E2311, E2313, E2361, E2377, E2617, E2624, K0108, K0861). 
 
You asked the Plan to pre-approve the Power Mobility Device. You say that the PMD is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 Power Mobility Device. Our 
reviewer says that a new group 3 PMD is not medically necessary. Our physician reviewer found the notes 
provided suggest the new device would not be able to be effectively used in the patient's kitchen due to lack of 
space and that he requires a wheelchair accessible apartment with a roll in shower. The record does now show 
that the enrollee could safely operate the new PMD within their home. Ongoing use of the current chair with 
repairs appears most medically appropriate. 
 
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 Power Mobility Device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Group 3 Power Mobility Device (PMD) with accessories (E1007, E1028, 
E2300, E2311, E2313, E2361, E2377, E2617, E2624, K0108, K0861).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided by you on July 29, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you 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 July 29, 2019. 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 provided by you on July 
29, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out-of-network skilled nursing facility 
(SNF) services provided from May 5, 2020, to May 25, 2020. 
 
You asked the Plan to waive the coinsurance for the out-of-network SNF services. You say that when the 
enrollee was discharged, you had no luck getting him into a network facility due to the short notice and 
COVID-19. The Plan denied your request. The Plan says this coinsurance was applied correctly.  The Plan 
identified five in-network SNFs that were available to the enrollee within 12 miles of the enrollee's home. 
 
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 contract with the Plan clearly says that enrollees must pay 50% 
coinsurance for out-of-network skilled nursing facility services.  
 
The enrollee has been asked to pay 50% coinsurance for the out-of-network SNF services. This means that the 
enrollee has been asked to pay the correct amount based on their contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay when they enrolled in the Plan. Therefore, we decided that the 
Plan does not have to waive the coinsurance for out-of-network skilled nursing facility (SNF) services provided 
from May 5, 2020, to May 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for diabetes self-monitoring supplies provided 
on June 12, 2020. 
 
You asked the Plan to waive the deductible for diabetes self-monitoring supplies. You say that you could not 
wait 4 weeks for your supplies so you had to purchase them from the pharmacy. 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. Your 
contract with the Plan says that there is a $500 deductible for diabetes self-monitoring supplies. 
 
You received diabetes self-monitoring supplies on June 12, 2020. The record shows that you had paid $0 
toward the $500 deductible prior to receiving the services. Therefore, you are responsible to pay the $500 
deductible.   
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category diabetes 
self-monitoring supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $500 deductible for diabetes self-monitoring supplies. This cost sharing is a contractual obligation that had 
not been met at the time diabetes self-monitoring supplies were received on June 12, 2020. Therefore, we 
decided that the Plan does not have to waive the deductible for diabetes self-monitoring supplies provided on 
June 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the A1C lab testing you had on July 6, 
2020. 
 
You asked the Plan to waive the copayment for the lab testing. You say that this lab services should be covered 
with a $0 copayment because it is considered a diabetes screening. The Plan denied your request. The Plan says 
you were charged this copayment correctly.  The Plan says that because the allowed amount for this lab testing 
is less than your copayment, you are responsible for the full 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 laboratory tests.  
 
You have been asked to pay 20% coinsurance for the lab testing. The lab testing falls within the laboratory tests 
benefit category. This testing is not considered diabetes screening.  In order to be considered diabetes 
screening, your doctor would have had to have billed one of the following codes for the test: 82947, 82950, or 
82951.  The A1C testing you had does not meet these criteria.  In addition, your doctor would have had to 
indicate that this test was ordered for diabetes screening purposes.  In order for that to be the case, your doctor 
would have had to have billed a diagnosis code of V.77.  Your doctor did not bill this diagnosis code, so there 
is no evidence that this was a diabetes screening test. 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 A1C lab testing you had on July 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist telehealth visits (99214 and 
99203) on May 11 and June 23, 2020. 
 
You asked the Plan to waive the copayments for specialist telehealth visits. You say that you are not satisfied 
with paying a copayment as the doctor really didn't do anything. The Plan denied your request. The Plan says 
the correct copayments were 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 each specialist visit.  
 
You have been asked to pay $90, or a $45 copayment for each of 2 specialist telehealth visits. Specialist 
telehealth visits fall 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 copayments for specialist telehealth visits (99214 and 99203) 
on May 11 and June 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic manipulative treatment (98943) mechanical 
traction (97012) electrical stimulation (G0283) provided on January 29, 2020. 
 
You asked the Plan to pay for the chiropractic services. You say that upon verification of this enrollee's policy, 
you were informed that chiropractic services are covered and no authorization is required. The Plan denied 
your request. The Plan says these services are not covered when rendered by a chiropractor. 
 
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 manipulative treatment (98943) mechanical traction (97012) 
electrical stimulation (G0283) provided on January 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of a Superion interspinous spacer device. 
 
You asked the Plan to pre-approve the Superion procedure. You say that the enrollee requires this treatment for 
his back pain. The Plan denied your request. The Plan says this treatment is not shown to be reasonable and 
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 the Superion procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the spacer remains 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 Superion procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of a Superion interspinous spacer device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a facet injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested procedure is supported if the reported pain is localized to either the neck 
or back, and does not travel to any other areas of the body. 
 
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 injection. Our reviewer says that the 
requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the requested procedure is supported for predominantly axial pain that is not associated with 
radiculopathy or neurogenic claudication.  The office notes indicate the patient has chronic low back pain with 
radiation into the buttock and leg.  The medical records document the diagnosis of lumbar radicular pain. The 
enrollee does not meet all of the criteria for coverage in LCD L35936 for the facet joint injection.  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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a facet injection for the enrollee.