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

We decided that the Plan does not have to pay for eye drainage (65800) and a bevacizumab injection (J9035)
provided on August 12, 2019.
You asked the Plan to pay for eye drainage and a bevacizumab injection. You say that these services were
medically necessary. The Plan denied your request. The Plan says these services were not billed correctly.
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 CPT code 65800 and J9035 is not supported in the medical record. Specifically, the CPT Code
Manual definition of code 65800 is paracentesis of anterior chamber of eye (separate procedure); with removal
of aqueous. The submitted medical records do not document that this drainage procedure was performed. The
billing of J9035 for intravitreal bevacizumab for administration in the office setting is not appropriate.
Medicare rules state that code J7999 should be used for this purpose. Based on this information, we decided
that Medicare rules for coverage of eye drainage and a bevacizumab injection have not been met. Therefore, we
decided that the Plan does not have to pay for eye drainage (65800) and a bevacizumab injection (J9035)
provided on August 12, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for occupational therapy and physical therapy 
provided by a participating provider on January 2, 2020. 
 
You asked the Plan to waive the copayment for occupational therapy and physical therapy. You say that you 
think you are being double billed. 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 $35 
copayment for outpatient rehabilitation services.  
 
You have been asked to pay a $35 copayment for occupational therapy and a $35 copayment for physical 
therapy. If you have more than one type of therapy during the same visit, a cost-sharing will apply to each type; 
therefore, you are being asked to pay a total amount of $70 ($35 x 2 therapies = $70). Occupational therapy and 
physical therapy falls within the outpatient rehabilitation 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 occupational therapy and physical therapy provided by a participating provider on 
January 2, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve acupuncture.
You asked the Plan to pre-approve acupuncture. You say that you would like the Plan to reconsider their
denial. The Plan denied your request. The Plan says that the services are not covered.
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. For acupuncture services performed on or after January 21, 2020, Medicare will
now provide limited coverage of acupuncture for patients with chronic low back pain (CLBP). The file shows
that the enrollee has CLBP. The Plan has not provided any medical records in order to determine if the enrollee
meets Medicare criteria for acupuncture services. It is the plan's responsibility to show that its decision to deny
coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases
where the plan has not supplied records from a plan provider that are critical to its decision, we may properly
find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plan's
failure to obtain records that are within the plan's control. The plan did not provide sufficient medical records
in order to determine if the enrollee meets Medicare criteria for acupuncture. Therefore, we decided that the
Plan has to pre-approve acupuncture.
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by an out of network
provider.
You asked the Plan to pre-approve physical therapy. You say that this provider knows exactly what the
problem is. You say that you have seen several network providers and they haven't been able to heal your ankle
and foot. The Plan denied your request. The Plan says the care you need is available within your network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
physical therapy to be provided by an out of network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services rendered on September 5, 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 procedure code J9035 is not supported. 
 
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 J9035 is injection, bevacizumab, 10 mg. 
 
We find that CPT code J9035 is not supported in the medical record. Specifically, the documentation shows 
that an Avastin injection for off label ophthalmic use was administered and there is a more appropriate code for 
these services. 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 injection services rendered on 
September 5, 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, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for clinic visit. You say that you are appealing based on medical necessity. The Plan 
denied your request. The Plan says the denial of payment for this service 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 February 6, 2020 
by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp (E1399). 
 
You asked the Plan to pre-approve a wheelchair ramp. You say that the wheelchair ramp is for the fractured hip 
and mobility issues due to that injury. It is a safety issue to be able to get in and out of the house without being 
assisted. The Plan denied your request. The Plan says this item is not medical in nature and is not a covered 
item. 
 
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 a wheelchair ramp (E1399).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a biopsy provided by a participating 
provider on December 19, 2018. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you do not agree with this 
because you did not have a biopsy done. 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 $350 
copayment for outpatient surgery.  
 
You have been asked to pay $317.60 which is less than your copayment amount of $350 for an outpatient 
surgery. If the procedure is discontinued after the beneficiary has received anesthesia or after the procedure was started 
(e.g., scope inserted, intubation started, incision made) the hospital may receive the full OPPS payment amount for the 
discontinued procedure. An outpatient surgery falls within the outpatient surgery 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 biopsy provided by a participating provider on December 19, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency ambulance service (A0429) and ground 
mileage (A0425) provided June 5, 2019. 
 
You asked the Plan to pay for the ambulance service. You say that you remain confused why the claim was not 
allowed and hope this appeal is successful. The Plan denied your request. The Plan says this claim cannot be 
reprocessed for payment until a corrected claim is received. 
 
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 claim was submitted with a TOB 130 which is non-payable. A corrected claim is required. 
Based on this information, we decided that Medicare rules for coverage of the ambulance service have not been 
met. Therefore, we decided that the Plan does not have to pay for emergency ambulance service (A0429) 
and ground mileage (A0425) provided June 5, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a telehealth visit for INR management 
provided on April 16, 2020. 
 
You asked the Plan to waive the copayment for telehealth visits. You say that this service is a short phone call. 
The Plan denied your request. The Plan says the copayment you are being charged is correct. 
 
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 $50 
copayment for in-network diagnostic procedures and tests at all locations of service.  
 
You have been asked to pay $11.59, which is less than your $50 copayment for a telehealth visit. A telehealth 
visit for INR management falls within the outpatient diagnostic tests and therapeutic services and supplies 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for a telehealth visit provided on 
April 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray services provided to the enrollee on February 21, 2020. 
 
You asked the Plan to pay for the services. You say that authorization is not required in this case. The Plan 
denied your request. The Plan says there was no 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 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 x-ray services provided to the enrollee on 
February 21, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for occupational therapy and physical therapy 
provided by a participating provider on April 10, 2020. 
 
You asked the Plan to waive the copayment for occupational therapy and physical therapy. You say that you do 
not agree with this additional 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 $35 
copayment for outpatient rehabilitation services.  
 
You have been asked to pay a $35 copayment for occupational therapy and a $35 copayment for physical 
therapy. If you have more than one type of therapy during the same visit, a cost-sharing will apply to each type; 
therefore, you are being asked to pay a total amount of $70 ($35 x 2 therapies = $70). Occupational therapy and 
physical therapy falls within the outpatient rehabilitation 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 occupational therapy and physical therapy provided by a participating provider on 
April 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the exercise equipment (A9300) purchased February 9, 2020. 
 
You asked the Plan to pay for the exercise equipment. You say that you are doing all you can to be proactive in 
not having a knee replacement. You had to purchase this through a TV channel due to the medical supply 
company not having this machine. The Plan denied your request. The Plan says this item is not covered. 
 
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 pay for the exercise equipment (A9300) purchased February 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested chiropractic services.
You asked the Plan to pre-approve the chiropractic services. You say that you have been with this provider for
years and you have confidence in this provider. The Plan denied your request. The Plan says you must receive
care from in-network providers with the exception of emergency or urgent care, or if the care cannot be
provided with an in-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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the
requested chiropractic services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for re-evaluation physical therapy and physical
therapy provided by a participating provider on May 12, 2020.
You asked the Plan to waive the copayment for re-evaluation physical therapy and physical therapy. You say
that you do not agree with this additional 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 $35
copayment for outpatient rehabilitation services.
You have been asked to pay a $35 copayment for re-evaluation physical therapy and a $35 copayment for
physical therapy. A separate copayment applies to the initial evaluation and any re-evaluations. Re-evaluation
physical therapy and physical therapy falls within the outpatient rehabilitation 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 re-evaluation physical therapy and physical therapy
provided by a participating provider on May 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or 
heat exchanger (99190) provided on February 25, 2020. 
 
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger. 
You say that this was a mandatory service. The Plan denied your request. The Plan says payment for this 
service is included in the DRG. 
 
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that 
CMS designates to be inpatient-only services. These services have an OPPS status indicator of C in the 
OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule.  
 
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of 
C on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as 
inpatient only, and therefore must be billed as part of an inpatient admission. Therefore, we decided that the 
Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger 
(99190) provided on February 25, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on April 1, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
the provider is not in-network and/or there is no authorization on file. 
 
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 subsequent nursing facility care provided on April 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician services provided a participating
provider on April 14, 2020.
You asked the Plan to waive the copayment for physician services. You say that this was part of your lab work.
You say that there shouldn't be a 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 $20
copayment for physician/practitioner services/specialist visit.
You have been asked to pay $12.49 which is less than your copayment amount of $20 for physician services.
Physician services fall within the physician/practitioner services/specialist visit 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 physician services provided a participating provider on April 14,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on December 9, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained.
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 physician services provided on December 9, 2019
by an out of network (OON) provider.