Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cardiac rehabilitation visit provided on 
January 3, 2022. 
 
You asked the Plan to waive the copayment for a cardiac rehabilitation visit. You say that you were misled by 
an insurance broker that had advised you that cardiac rehab would be covered in full when you enrolled in the 
Plan. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $45 
copayment for an in-network cardiac rehabilitation visit.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$45 copayment for a cardiac rehabilitation visit. A cardiac rehabilitation visit falls within the Cardiac 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 a cardiac 
rehabilitation visit provided on January 3, 2022.  
 
Your complaint about the insurance broker giving you incorrect information is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the specialist office visit. You say that the in-network provider that you saw 
prior you did not have a good experience with and would like to see an out-of-network provider because of the 
high reviews and expertise. The Plan denied your request. The Plan says a list of in-network providers was 
given to the enrollee that provide the same quality of service, are accepting new patients, and are close to the 
enrollee's residence. 
 
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 
a specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the records show that the enrollee's rehabilitation can be safely provided at a lower 
intensity and alternate setting such as in a skilled nursing facility.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy provided 
on August 17, 2021. 
 
You asked the Plan to waive the copayment for an esophagogastroduodenoscopy. You say that you do not owe 
this copayment because you already paid the doctor $35. You also say that you cannot afford $350 every other 
year for this procedure. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing 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 $350 
copayment for same day outpatient surgery in a freestanding ambulatory surgical center.  
 The record shows that an esophagogastroduodenoscopy is considered a surgical procedure. The record also 
shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a $350 
copayment for an esophagogastroduodenoscopy. An esophagogastroduodenoscopy falls within the Outpatient 
Hospital 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 an 
esophagogastroduodenoscopy provided on August 17, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve inpatient rehabilitation facility (IRF) care. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
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. The case file was requested and never received from the health plan. Without 
this information, the plan's denial is not able to be substantiated. Therefore, we decided that the Plan has to pre-
approve inpatient rehabilitation facility (IRF) care.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network 
(OON) provider on November 18, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on  
November 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on December 15, 2021. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says Medicare does 
not cover services when a physician opts out of Medicare. 
 
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 who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
physician's services provided on December 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the 
pelvis provided on December 15, 2021. 
 
You asked the Plan to waive the copayment for an MRI. You say that you had the MRI done and it came back 
that they only did half of the MRI because the other half was inclusive. You also say that the provider had to do 
surgery on your colon to see what the MRI did not show, and you should not have to pay for something they 
did not do correctly. The Plan denied your request. The Plan says you have been charged the correct sharing 
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 $275 
copayment for each diagnostic imaging service, including MRIs.  
 The medical record shows you had an MRI performed on December 15, 2021. The record shows this claim was 
approved, and you have a cost sharing amount. You have been asked to pay a $275 copayment for an MRI. An 
MRI 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 magnetic resonance imaging (MRI) of the pelvis provided 
on December 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a portable oxygen concentrator provided 
from September 27, 2021, to December 27, 2021. 
 
You asked the Plan to waive the coinsurance for a portable oxygen concentrator. You say that your portable 
oxygen concentrator had malfunctioned, and it needed to be replaced. You also that that the provider told you 
that you should not have to pay for a new rental contract for this item as it is covered by your insurance. The 
Plan denied your request. The Plan says you have been charged the correct cost sharing 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 durable medical equipment.  
 
 The record shows these claims were approved, and you have a cost share amount. You have been asked to pay 
$7.49, which is 20% coinsurance for a portable oxygen concentrator on September 27, 2021, October 27, 2021, 
November 27, 2021, and December 27, 2021 ($37.47 allowed amount x 20% coinsurance = $7.49). A portable 
oxygen concentrator 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 a portable oxygen concentrator provided from 
September 27, 2021, to December 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiidra. 
 
You asked the Plan to pre-approve Xiidra. You say that Xiidra is medically necessary. The Plan denied your 
request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xiidra.  
 
Benefits for Xiidra may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the mammogram on January 6, 2022. 
 
You asked the Plan to waive the deductible for mammogram. You say that you had to have a second 
mammogram due to an error by the technician on your initial visit. You say that you should not be responsible 
for the charges billed for this visit. The Plan denied your request. The Plan says the deductible 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 there is $750 out-of-
pocket deductible which applies to certain items and services. 
 
The item or service you asked the Plan to waive the deductible for falls within the Outpatient diagnostic tests 
and therapeutic services and supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that the $750 deductible applies to diagnostic mammograms. 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 deductible for the mammogram on January 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for an ankle orthosis and an addition to the 
lower extremity orthosis provided on January 4, 2022. 
 
You asked the Plan to reduce the cost share for an ankle orthosis and an addition to the lower extremity 
orthosis. You say that you had to change your fitting appointment for the ankle brace because you were sick. 
You also say you paid $155.26 when the order was placed, and you should not be penalized by not going to the 
appointment in December when you were sick. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing 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 there is a $450 
deductible which applies to certain items and services. The Plan deductible applies to in-network durable 
medical equipment. The Plan contract also says that you must pay 20% coinsurance for in-network durable 
medical equipment.  
 
The record shows this claim was approved, and you have a cost sharing amount. The deductible was not met at 
the time of service; therefore, $450 was applied to your deductible. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is $450 deductible which applies to durable medical equipment. 
This cost sharing is a contractual obligation that had not been met at the time the ankle orthosis was received 
on January 4, 2022. 
 
You have been asked to pay a total of $523.17 for an ankle orthosis and an addition to the lower extremity 
orthosis on January 4, 2022. The allowed amount remaining after you paid your deductible is $$280.21 
($730.21 original allowed amount - $450 deductible paid = $280.21 remaining allowed amount). You have 
been asked to pay $56.04, which is 20% of the remaining allowed amount for the ankle orthosis ($280.21 
remaining allowed amount x 20% coinsurance = $56.04). You have also been asked to pay $17.13, which is 
20% coinsurance for the addition to the lower extremity orthosis ($85.67 allowed amount x 20% coinsurance = 
$17.13). An ankle orthosis and an addition to the lower extremity orthosis 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 reduce the cost share 
for an ankle orthosis and an addition to the lower extremity orthosis provided on January 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this service is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is considered 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628, 64629).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the advanced care planning rendered December 4, 2021. 
 
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 99497 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 99497 (advanced care planning) and 99223 (initial hospital 
care). Code 99497 is a column II code with a modifier indicator of 1 when billed with column I code 99223. 
Code 99497 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided 
that the Plan does not have to pay for the advanced care planning rendered December 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit and outpatient 
diagnostic tests provided on October 26, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit and outpatient diagnostic tests. You 
say that you are retired and on a modest fixed income. The Plan denied your request. The Plan says the 
copayments 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 $50 
copayment for each in-network specialist office visit and a $75 copayment for each covered outpatient 
diagnostic test at an in-network doctors office. 
 
You have been asked to pay a total of $109.82 for the specialist office visit, electrocardiogram (ECG) and x-
ray.  
 
Service Allowed Amount Standard Copayment Member Liability 
Specialist Visit $155.82 $50 $50 
ECG $18.33 $75 $18.33 
X-Ray $41.49 $75 $41.49 
TOTAL:   $109.82 
 
Specialist office visits fall within the Physician/Practitioner services, including doctor's office visits benefit 
category. The ECG and x-ray 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 the specialist office visit, ECG 
and x-ray provided on October 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82728, 83540, 83550) provided July 26, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says these services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that all laboratory services furnished to individuals 
for the treatment of End-Stage Renal Disease (ESRD) are included in the ESRD PPS as Part B services and are 
not paid separately as of January 1, 2011. 
 
We looked at the file and Medicare rules. The payment for this service is included in the payment to the ESRD 
facility. Based on this information, we decided that Medicare rules for coverage of the lab services have not 
been met. Therefore, we decided that the Plan does not have to pay for lab services (82728, 83540, 83550) 
provided July 26, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the non-emergent taxi transportation service 
(A0100) provided on March 5, 2021. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not covered by Medicare. 
Additionally, this service was rendered by an out-of-network provider, without prior authorization. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Additionally, the Plan contract says that you 
must use the plans approved vendor for routine transportation services. Routine transportation services are 
provided by a contracted vendor.  
 
We find that CPT code A0100 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code A0100 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of this service have not been met. Additionally, this service was rendered by an out-of-network 
provider, without prior authorization. Therefore, we decided that the Plan does not have to issue reimbursement 
for the non-emergent taxi transportation service (A0100) provided on March 5, 2021.