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

 
We decided that the Plan does not have to waive the copayment for the ultrasound exam of the head and neck 
(76536) provided on February 19, 2020. 
 
You asked the Plan to waive 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 $125 
copayment for each in network Medicare-covered radiological diagnostic service performed in a physician?s 
office or at a free-standing facility such as a radiology center or medical clinic.  
 
You have been asked to pay a $119 copayment for the in network Medicare-covered radiological diagnostic 
service provided in your physician's office. This amount is the Plan allowed amount which is less than the 
applicable copayment. 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 exam of the head 
and neck (76536) provided on February 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on April 8, 2020. 
 
You asked the Plan to pay for the testing services. You say that the testing was ordered to determine if there 
was a more effective therapy to treat the enrollee. The Plan denied your request. The Plan says there is a more 
appropriate code to describe the services provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the services at issue were not billed according to Medicare coding and billing guidelines. Based on 
this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for the Guardant360 testing provided on April 8, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to waive the additional copayment applied to the application of a multi-layer 
compression system to the leg during an occupational therapy visit provided on March 31, 2020 billed with 
code 29581-GO. 
 
You asked the Plan to waive the additional copayment applied to the compression system application. You say 
that it is felt that an additional copayment is not appropriate as this compression wrapping is a part of the 
occupational therapy plan of care and is billed as such. The Plan denied your request. The Plan says that a 
specialist service copayment was correctly applied to code 29581. 
 
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 says that enrollees must pay a 
$40 copayment for Medicare-covered occupational therapy visits. 
 
The Plan says the enrollee must pay an additional $45 copayment for specialist services provided on this date 
of service. However, based on the contract, the enrollee cannot be asked to pay more than a $40 copayment for 
a single occupational therapy visit. The code 29581 was billed with a GO modifier indicating it was performed 
as part of the occupational therapy plan of care. There is no language in the contract which would create a 
reasonable expectation that an additional copayment would be applied to a service provided during an 
occupational therapy visit. There is likewise no evidence to support applying a specialist copayment to this 
service as it appears this care would have been rendered by the same provider who performed the manual 
therapy. Therefore, we decided that the Plan has to waive the additional copayment applied to the application 
of a multi-layer compression system to the leg during an occupational therapy visit provided on March 31, 
2020 billed with code 29581-GO.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to adjust the copayment for rehabilitation services received on May 1, 2019. 
 
You asked the Plan to adjust the copayment for the services. You say that you should be reimbursed $30, as 
you overpaid. The Plan denied your request. The Plan says that they did not come to a decision in time. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $30 copayment for outpatient rehabilitation services.  
 
The Plan says you must pay a $60 copayment for the services. Based on the Plan contract, however, you cannot 
be asked to pay more than a $30 copayment for the services. The plan should reimburse you the full $30 extra 
paid for these services. Therefore, we decided that the Plan has to adjust the copayment for rehabilitation 
services received on May 1, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency department visit (99282) 
provided February 14, 2020. 
 
You asked the Plan to waive the copayment for the emergency department visit. You say that the entire time in 
the ER was spent standing up. You had no bed, no tests were taken and nothing was done. You are requesting 
an appeal. It is unfair to charge you $90 for this situation. The Plan denied your request. The Plan says this 
claim processed correctly and the correct copayment was applied per the plan benefits. 
 
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 $90 
copay for Emergency care.  
 
You have been asked to pay $90 copay for the emergency department visit. The emergency department 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 department visit (99282) provided February 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for proton beam radiation therapy (77523, 77336, G6002) 
provided from February 13, 2020 to March 13, 2020. 
 
You asked the Plan to pay for proton beam radiation therapy. You say that this should be covered. The Plan 
denied your request. The Plan says this is not the standard of care and the registry study does not qualify as a 
clinical trial. 
 
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 pay for proton beam radiation therapy. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found notably lacking in the case file are any specific dosimetric rationales for the need of 
proton therapy in this specific patient that would translate into a plausible clinical benefit. The published data 
used to support proton therapy for gliomas is scant and represents small studies, dosimetric comparisons and/or 
studies which include a mixed bag of tumor types. Thus, proton therapy would not be considered an accepted 
medical standard.  
 
The appeal documentation indicates that the patient agreed to consent to a registry study. Registry studies are 
not clinical trials or studies, and have a much less rigorous development process.  A tumor registry does not 
address a specific scientific question but rather registers the patient?s clinical and treatment information into a 
database for potential analysis in the future. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pay for proton beam radiation therapy (77523, 77336, G6002) provided from 
February 13, 2020 to March 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the inpatient hospital services provided from 
February 1, 2020 to February 3, 2020. 
 
You asked the Plan to waive the copay for the inpatient hospital services. You say that this should be paid at 
the in network rate. The Plan denied your request. The Plan says that the claim processed 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 
copay per day for days 1-5 of inpatient hospital care.  
 
You have been asked to pay a $650 copay for the inpatient hospital services. The inpatient hospital services fall 
within days 1-5 of 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 copay for 
the inpatient hospital services provided from February 1, 2020 to February 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Medicare Part B prescription drugs. 
 
You asked the Plan to waive the coinsurance for the Medicare Part B prescription drugs. You say that you 
cannot afford this coinsurance. 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 a 15% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 15% coinsurance for the Medicare Part B prescription drugs. the Medicare Part 
B prescription drugs 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 the Medicare Part B prescription drugs.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee scooter (E0118) provided on August 10, 2019. 
 
You asked the Plan to pay for the knee scooter. You say that you would like reconsideration because you were 
told you had authorization to get this product from an out-of-network provider. The Plan denied your request. 
The Plan says durable medical equipment must be supplied by a Medicare participating provider. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Additionally, the knee scooter (E0118) is not a Medicare 
covered benefit. Therefore, we decided that the Plan does not have to pay for a knee scooter (E0118) provided 
on August 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy, antibiotic, antiviral, or antifungal 
therapy; once every 24 hours; administrative services, professional pharmacy services, care coordination, and 
all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (Code S9500) 
provided from February 14, 2020 through February 15, 2020. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the Medicare rules 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. 
 
Procedure code S9500 has a status code of I which is not valid for Medicare purposes. 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 infusion therapy, antibiotic, antiviral, or antifungal 
therapy; once every 24 hours; administrative services, professional pharmacy services, care coordination, and 
all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (Code S9500) 
provided from February 14, 2020 through February 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-share for diagnostic radiological services provided on 
July 2, 2019. 
 
You asked the Plan to waive the cost-share for diagnostic radiological services. You say that you are appealing 
your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the 
claim was processed accordingly with your 2019 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
On January 9, 2019, you received radiological diagnostic services with Medicare-allowed total of $116.36. At 
the time of claim processing, you had not met any of your $300 2019 deductible; therefore, the entire 
Medicare-allowed amount of $116.36 was applied to your 2019 deductible. 
 
On July 2, 2019, you received radiological diagnostic services with Medicare-allowed total of $363.93. At the 
time of claim processing, you had only met $116.36 of your $300 2019 deductible; therefore, $183.64 of the 
Medicare-allowed amount was applied to your 2019 deductible ($116.36 + $183.64 = $300). The remaining 
Medicare-allowed balance of $180.29 ($363.93 - $183.64) is subject to the 20% coinsurance for each 
Medicare-covered radiological diagnostic service, not including X-rays.  
 
The cost-share for clinical services assessed correctly per your 2019 EOC. The overall cost-share is calculated 
by taking the Medicare-allowed amount and subtracting the plan paid amount and the sequestration amount. In 
this case: $363.93 Medicare-Allowed - $141.36 Plan Paid - $2.88 Sequestration = $219.69 Cost-Share Due. 
Cost-sharing is a contractual obligation of the plan and cannot be waived. 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 diagnostic radiological services provided on July 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on December 16, 2019 to 
December 19, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for practitioner visits. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of payment for these services is correct, because this 
provider is out-of-network with the Plan and authorization was not 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 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 December 16, 
2019 to December 19, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for destruction by neurolytic agent, paravertebral facet joint 
nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (CPT 
Code 64634) and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance 
(fluoroscopy or CT); cervical or thoracic, single facet joint (CPT Code 64633) provided from May 21, 2020 
through May 28, 2020. 
 
You asked the Plan to pay for the services. You say that these should a covered benefit and you were unaware 
of any cost. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Review of the records show that 
you had a thermal radio-frequency ablation to the right and left sides of medical branches of C3, C4, and C5 
articular pillars on May 21, 2020 and May 28, 2020. The medical records indicated that you had the same areas 
injected on April 28, 2020 and May 6, 2020. According to the Centers for Medicare and Medicaid Services 
(CMS) LCD for Facet Joint Interventions for Pain Management (L34892), repeat thermal facet joint RF 
ablation at the same anatomic site is considered medically reasonable and necessary provided the patient had a 
minimum of 50% improvement in pain for at least six (6) months. Additionally, repeat thermal RF ablation at 
the same anatomic site (same side [R/L or Bilateral] and spinal level) must be performed at a minimum of six 
(6) months from a prior treatment at that site. Based on the above information, the claims are processing and 
denying for meeting your benefit maximum appropriately. There must be a minimum of six months between 
each procedure.  
Therefore, we decided that the Plan does not have to pay for destruction by neurolytic agent, paravertebral facet 
joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint 
(CPT Code 64634) and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging 
guidance (fluoroscopy or CT); cervical or thoracic, single facet joint (CPT Code 64633) provided from May 
21, 2020 through May 28, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home visit assistance for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is a supplemental service which is not covered by Medicare.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is no documentation that home visits for assistance with activities of daily living and personal care in this case are medically reasonable and necessary. Home health aide services are only covered by Medicare when there is a documented skilled need requiring skilled nursing and/or therapy. No skilled needs are identified for the enrollee in this case based on the provided records.

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve home visit assistance for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Synvisc injection. 
 
You asked the Plan to pre-approve a Synvisc injection. You say that the requested Synvisc injection is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a 
Synvisc injection. 
 
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 a Synvisc injection. Our reviewer says 
that the enrollee does not meet criteria for a Synvisc injection. Our physician reviewer found this enrollee has a 
history of chronic knee pain following a fall in June 2018. There is radiographic evidence of right knee 
osteoarthritis, including medial and patellofemoral joint space narrowing and marginal osteophyte formation. 
She has been treated with cortisone injections. Under consideration is a request for right knee Synvisc 
injection. Medicare coverage criteria have not been met at this time. The current medical records do not 
document any right knee subjective complaints or specific functional limitations. There is no discussion of pain 
disrupting sleep, crepitus or knee stiffness. There is no documentation in the medical records that the enrollee 
had failed or had contraindication to at least 3 months of conservative therapy, including home exercise, weight 
loss, physical therapy, simple analgesics or NSAIDs. Therefore, the enrollee does not have a covered indication 
for the requested Synvisc injection 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 a Synvisc injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Synvisc injection.