Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment (DME) 
provided on April 12, 2021, to May 12, 2021. 
 
You asked the Plan to waive the coinsurance for DME. You say that this should be covered. The Plan denied 
your request. The Plan says the coinsurance applied 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 20% 
coinsurance for Medicare covered benefits. 
 
You have been asked to pay $311.52 which is 20% of the allowed amount for DME. The allowed amount is 
$1,557.60 (20% x $1,557.60 = $311.52). DME falls within the Durable Medical Equipment (DME) and 
Related 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 coinsurance for durable medical 
equipment (DME) provided on April 12, 2021, to May 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle-foot orthosis rendered on February 15, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid face-to-face encounter. 
 
The Plan must follow Medicare rules. The rules say that an in-person, face-to-face interaction between the 
beneficiary and their treating physician is required prior to prescribing durable medical equipment (DME). 
 
We looked at the file and Medicare rules. The file shows that there is no valid face-to-face encounter for the 
DME. 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 ankle-foot orthosis rendered on February 
15, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on August 16, 
2021. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you should not be responsible 
for this cost share. The Plan denied your request. The Plan says the cost share was 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). Your contract with the Plan clearly says that you must pay a $20 
copayment for Medicare-covered physical therapy visits.  
 
You have been asked to pay $20 for physical therapy. 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 physical therapy provided on August 16, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health aide or certified nursing assistant (S9122) 
provided from December 20, 2021, to December 31, 2021. 
 
You asked the Plan to pay for the home health services. You say that the services were denied because the 
provider is not certified for Medicare. You say that you have tried to get clarification on why the services were 
denied. You also say that you do not understand why these services were not paid. The Plan denied your 
request. The Plan says the provider in this case is not eligible to participate in Medicare. The Plan also says 
payment cannot be made to a provider that is not eligible to participate in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the home health aide or certified nursing 
assistant (S9122) provided from December 20, 2021, to December 31, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve home health aide services. You say that home health aide is medically 
necessary. The Plan denied your request. The Plan says home health aide is not medically necessary. 
 
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.  
 
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 home health aide services. Our 
reviewer says that home health aide services are not medically necessary. Our physician reviewer found that 
the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled 
therapy needs. There is no evidence that associated HHA services are needed to assist in the treatment of an 
illness or injury. The requested services appear to be custodial.  As such, the requested HHA services are not 
medically necessary, reasonable or coverable.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home health aide services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a smoking and tobacco use cessation counseling visit 
provided on February 23, 2022, by an OON provider. 
 
You asked the Plan to pay for a smoking and tobacco use cessation counseling visit. You say to please review 
the documentation and reconsider the claim for full payment. The Plan denied your request. The Plan says the 
out-of-network services were not authorized. 
 
 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 had network providers 
available who could have provided 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 a smoking and tobacco use cessation counseling 
visit provided on February 23, 2022, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for surgery on January 25, 2022. 
 
You asked the Plan to waive the copayment for surgery. You say that if you were told there was a copay for 
services, then you would have denied services. The Plan denied your request. The Plan says the cost sharing 
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 $250 
copayment per visit for Medicare-covered outpatient surgery. Additional copays and/or coinsurance may apply 
depending upon the Medicare-covered outpatient service received. If you are having surgery in a hospital 
facility, you should check with your provider about whether you will be an inpatient or outpatient. Unless the 
provider writes an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost-
sharing amounts for outpatient surgery. Even if you stay in the hospital overnight, you might still be considered 
an outpatient. The provider billed in the amount of $298.36 and the allowed amount is $245.97. This is less 
than the copayment amount. Therefore, results in the total cost sharing amount of $245.97. You have been asked to pay a $245.97 copayment, which is less than the copayment amount for surgery. 
Surgery 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 surgery on 
January 25, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient observation on May 02, 2022. 
 
You asked the Plan to waive the copayment for outpatient observation. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says the cost sharing 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 $325 
copayment for the outpatient hospital observation per stay. Observation services are hospital outpatient services 
given to determine if you need to be admitted to an inpatient or can be discharged. For outpatient hospital 
observation services to be covered, they must meet the Medicare criteria and be considered reasonable and 
necessary. Observation services are covered only when provided by the order of a physician or another 
individual authorized by state licensure law and hospital staff bylaws to admit patients to the hospital or order 
outpatient tests.  
 
 
 You have been asked to pay a $325 copayment for outpatient observation. Outpatient observation falls within 
the Outpatient hospital observation 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 
outpatient observation on May 02, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit rendered on January 17, 2022. 
 
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 99203 is not covered. 
 
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. The file shows that the 
chiropractor billed code 99203 (office visit). Therefore, we decided that the Plan does not have to pay for the 
office visit rendered on January 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the observation or inpatient hospital care rendered on March 
12, 2022. 
 
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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that payment for an initial observation care code is for all 
the care rendered by the ordering physician on the date the patients observation services began. 
 
We looked at the file and Medicare rules. The file shows that procedure code 99220 (initial observation care 
evaluation and management service) was billed one day prior to the services at issue. Therefore, we decided 
that the Plan does not have to pay for the observation or inpatient hospital care rendered on March 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for foot orthotics provided on March 22, 
2022. 
 
You asked the Plan to waive the coinsurance for foot orthotics. You say that you were told they would be 
covered in full. The Plan denied your request. The Plan says the coinsurance applied 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 20% 
coinsurance for covered items and related supplies.  
 
You have been asked to pay $123.11 which is 20% of the allowed amount for foot orthotics. The allowed 
amount is $615.54 (20% x $615.54= $123.11).  Foot orthotics fall within the Durable Medical Equipment 
(DME) and Related 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 coinsurance for foot 
orthotics provided on March 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29823 billed for date of service July 7, 2021. 
 You asked the Plan to pay for procedure code 29823. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 29823 is bundled into payment for code 29807. 
 
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, we have confirmed that code 29823 
is a column II code to column I code 29807. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code 29823 billed for date of service July 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard, power wheelchair, sling/solid 
seat/back, patient weight capacity up to and including 300 pounds (K0822). 
 
You asked the Plan to pre-approve a power wheelchair. You say that the enrollee has been waiting months for 
medical equipment. The enrollee is non-compliant, and a motorized wheelchair is a risk for her. The Plan 
denied your request. The Plan says as a requirement of Medicare, in order to evaluate the need for a motorized 
chair or scooter, your physician must submit a face-to-face document, which includes an assessment of your 
ability to safely operate the equipment in your home, limitations and conditions you have that warrant the use 
of the equipment. The face-to-face document received is not completed, therefore, the enrollee does not meet 
criteria. 
 
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 patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 The file shows that you cannot safely operate the PMD being requested. This means that Medicare rules for 
coverage of a PMD have not been met. Per Medicare rules, in order to evaluate a need for a power wheelchair, 
a face-to-face must be completed by the physician. Specifically, the needed document received is not 
completed. Therefore, we decided that the Plan does not have to pre-approve a group 2 standard, power 
wheelchair, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0822).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visit provided on March 31, 2022. 
 
You asked the Plan to waive the copayment for ER visit. You say that you never received any care and left the 
ER so you shouldn't have to pay. The Plan denied your request. The Plan says the copayment applied 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 $90 
copayment for Medicare-covered emergency room visits.  
 
You have been asked to pay $90 copayment for ER visit. ER visits fall 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 ER visit provided on March 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on April 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says services from non-participating providers are not covered unless 
preauthorized. 
 
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 had network providers 
available who could have provided 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 psychotherapy provided on April 14, 2022, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for CT scan provided on February 18, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you thought this was covered since your 
doctor ordered it. The Plan denied your request. The Plan says the copayment applied 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 $350 
copayment per day for other Medicare-covered diagnostic radiology services that are not ultrasounds.  
 
You have been asked to pay $350 copayment for CT scan. CT scans fall 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 CT scan provided on February 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (74220) provided on March 21, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
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, we have confirmed that code 74220 
is a column II code to column I code 74230 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for the services (74220) provided on March 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a carryover of the over-the-counter benefit allowance 
per quarter. 
 
You asked the Plan to pre-approve a carryover of the over-the-counter benefit allowance per quarter. You say 
that on June 30, 2022 you were in the process of getting your order together and adding to the cart when your 
internet went out and since your phone is through Google, you were not able to call and place the order over 
the phone either. You say that as soon as your internet was back up on July 1, 2022, you called the Plan to 
advised them within 24 hours and also called the over-the-counter telephone number within 48 hours to advise 
and this is why you feel that your 2nd quarter over-the-counter allowance should be reinstated as it was not 
your fault the internet went down and you could not order your needed supplies. The Plan denied your request. 
The Plan says per your Plan benefit, quarterly allowances cannot be carried over to another quarter. 
 
The Plan contract covers a supplemental over-the-counter benefit. The Plan contract says quarterly allowances 
cannot be carried over to another quarter. 
 
We looked at the file and the Plans rules. The file shows that quarterly allowances cannot be carried over to 
another quarter. Therefore, we decided that the Plan does not have to pre-approve a carryover of the over-the-
counter benefit allowance per quarter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 14, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76376 billed for date of service March 22, 
2022. 
 
You asked the Plan to pay for procedure code 76376. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76376 is bundled into payment for 
code 78072. 
 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, we have confirmed that code 76376 
is a column II code to column I code 78072. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76376 billed for date of service March 22, 2022.