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

 
We decided that the Plan does not have to waive the copayment for radiation therapy services provided from 
April 19, 2021, to April 22. 
 
You asked the Plan to waive the copayment for the radiation therapy services. You say that the services should 
be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the 
services 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 $60 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 You have been asked to pay a $240 copayment for four radiation therapy service visits. Radiation therapy 
services 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 radiation therapy services provided from April 19, 2021, to 
April 22.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional supplies or staff time (99072) provided September 
17, 2021. 
 
You asked the Plan to pay for the additional supplies or staff time. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the code billed is not separately payable. 
 
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 99072 is not supported in the medical record. Specifically, per the National Physician 
Fee Schedule, this code has a status of "B" and payment is always bundled with another service. Based on this 
information, we decided that Medicare rules for coverage of the additional supplies or staff time have not been 
met. Therefore, we decided that the Plan does not have to pay for additional supplies or staff time (99072) 
provided September 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99222) provided August 19, 2021. 
 
You asked the Plan to pay for the physician services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the billed code shares a bundled relationship with another code 
billed and is not separately payable. 
 
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 99222 
is a column II code to column I code 99223. 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 physician services (99222) provided August 19, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the non-emergent ambulance transportation 
services (A0428, A0425) provided on September 28, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that this was supposed to be 
routine transportation and you were told this would be provided at no cost to you. The Plan denied your 
request. The Plan says the transportation services were provided in an ambulance, which was medically 
necessary and requires a $50 copayment. 
 
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 ambulance transportation trip.  
 
 You have been asked to pay a $50 copayment for the ambulance transport. 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 non-emergent ambulance transportation services (A0428, A0425) provided on 
September 28, 2021.  
 
Your complaint about potential misinformation from a Plan representative 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 pay for hospital subsequent care provided on August 7, 2021. 
 
You asked the Plan to pay for the hospital subsequent care. You say that you were hospitalized, and you did not 
pick the doctor who saw you. The Plan denied your request. The Plan says the hospital stay was not prior 
authorized and the provider is non-contracted with the Plan. The Plan will only cover non-contracted providers 
if the service is for an emergency and if it is medically necessary to go out of 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 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 hospital subsequent care provided on August 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (36415, 80053, 80061, 82306, 83735) 
rendered by the out-of-network (OON) provider on October 1, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. 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 the laboratory services (36415, 80053, 80061, 82306, 83735) rendered by the out-
of-network (OON) provider on October 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services provided on September 14, 2021, billed 
with codes 75726-59 and 75774-59. 
 
You asked the Plan to pay for the surgical services as billed. You say that these services were billed correctly. 
The Plan denied your request. The Plan says these two codes are not separately payable when billed along with 
37244. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Codes 75726 and 75774 are Column 2 codes in relation to code 37244. Modifier -59 was used to bypass this 
edit. 
 
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 the surgical services as billed. Our reviewer 
says that the services are not shown to be separately payable along with code 37244. Our physician reviewer 
found the enrollee is an 84-year-old woman who presented with hypotension and concern for acute 
gastrointestinal bleed with hypovolemic shock. The enrollee was acutely unstable. Interventional radiology was 
consulted. Celiac and superior mesenteric angiography showed large hemorrhage from the 
gastroduodenal artery. Embolization of the gastroduodenal artery across the hemorrhage was performed into 
the inferior pancreaticoduodenal artery. An inferior vena cava filter was placed. 
 
The documentation is insufficient to support the use of modifier -59 to bypass the NCCI edit between 75726 
and 37244. The documentation is insufficient to support the use of modifier -59 to bypass the NCCI edit 
between 75774 and 37244. 
 
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 surgical services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the surgical services provided on September 14, 2021, billed with codes 75726-
59 and 75774-59.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, 
non-emergent transport (A0428) provided on September 17, 2021. 
 
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 $275 
copayment for out-of-network Medicare-covered ground and air ambulance benefits (per one way) and is based 
on the Medicare allowable. 
 You have been asked to pay $218.50 for the out-of-network Medicare-covered ground ambulance service 
provided. This is the Plans allowed amount for this service 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 ambulance service, basic life support, non-emergent 
transport (A0428) provided on September 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 20, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 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 70544 
is a column II code to column I code 70551. 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 imaging services provided to the enrollee on October 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a whole-mouth 
X-ray survey (D0210) provided on October 26, 2021. 
 
You asked the Plan to pay for a comprehensive oral evaluation and a whole-mouth X-ray survey. You say that 
no one told you that the procedures at issue are covered once every 3 years. The Plan denied your request. The 
Plan says rules for payment have not been met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a 
comprehensive oral evaluation and a whole-mouth X-ray survey once every 3 years.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a comprehensive oral evaluation and a whole-mouth X-ray survey have not been met. Specifically, the Plan has documented that you received the services at issue less than 3 years before the date of service at 
issue. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
and a whole-mouth X-ray survey (D0210) provided on October 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management services provided 
August 8, 2021. 
 
You asked the Plan to pay for hospital discharge day management services. You say that you were hospitalized, 
and you did not pick the doctor who saw you. The Plan denied your request. The Plan says the hospital stay 
was not prior authorized and the provider is non-contracted with the Plan. The Plan will only cover non- 
contracted providers if the service is for an emergency and if it is medically necessary to go out of 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 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 hospital discharge day management services provided on  
August 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for treatment with Lanreotide injection 
(J1930, 96402) provided on November 9, 2021. 
 
You asked the Plan to waive the coinsurance for Lanreotide. You say that you have never before had to pay for 
these sorts of injections. The Plan denied your request. The Plan says the correct coinsurance was 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 20% 
coinsurance for Medicare-covered Part B prescription drugs.  
 
You have been asked to pay $1,205.97, or 20% of the Medicare-allowed charge of $6,029.83, for Lanreotide. 
Lanreotide 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 treatment with Lanreotide injection (J1930, 
96402) provided on November 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a home ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says you are not compliant with the usage of the device and your records indicate you 
are not using the recommended device. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found continued 
coverage of a home ventilator, beyond that already approved, is not medically necessary, unless you are able to 
meet Medicare compliance requirements. You have had a Trilogy ventilator since 2019. The usage data for 
12/11/19 - 5/30/21 shows that on 32.6% of days, usage was at least four hours.  This is not enough for the device to be effective, and does not meet Medicare minimum requirement of at least 
4 hrs/day for at least 70% of days. The Plan has approved continued coverage for 3 months to provide an 
opportunity to meet usage criteria. The denial for the remaining requested months is appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued use of a home ventilator.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance services provided on August 12, 2020. 
 
You asked the Plan to pay for air ambulance services. The Plan denied your request. The Plan says the time 
limit for filing the claim has expired. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for air ambulance services was not filed until September 9, 2021. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for air ambulance services provided on August 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for advanced imaging services and office visits 
provided from September 14, 2021, to October 19, 2021. 
 
You asked the Plan to waive the copayment for the advanced imaging services and office visits. You say that 
the services should be covered in full as they are COVID-19 related. The Plan denied your request. The Plan 
says the cost-sharing applied correctly based on the services 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 $150 
copayment for Outpatient diagnostic tests and therapeutic services and supplies and a $30 copayment for 
Physician/Practitioner services, including doctors office visits. 
 You have been asked to pay a $30 copayment for an office visit, a $30 copayment for an ultrasound, and a 
$150 copayment for the advanced imaging services. There are no Plan guidelines that state services rendered 
due to COVID-19 would be waived in full. 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 advanced 
imaging services and office visits provided from September 14, 2021, to October 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 17, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the codes were not billed with an allowed modifier. 
 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 70450 
is a column II code to column I code 70496. 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 imaging services provided to the enrollee on October 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (99233) provided September 22, 2021. 
 You asked the Plan to pay for the hospital care. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the service billed shares a column I / column II relationship with another 
code billed. 
 
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 99233 
is a column II code to column I codes93016 & 93018. 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 hospital care (99233) provided September 22, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cyanocobalamin 1000mg injections. 
 
You asked the Plan to pre-approve Cyanocobalamin. You say that this drug is medically necessary. The Plan 
denied your request. The Plan says only drugs being billed by the physician are eligible for coverage under the 
Part B medical benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Cyanocobalamin 1000mg injections.  
 
Benefits for Cyanocobalamin 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Toric IOL provided on June 21, 2021. 
 
You asked the Plan to pay for the Toric IOL. You say that you were advised the lens was necessary due to 
severe astigmatism. The Plan denied your request. The Plan says Medicare only covers conventional IOL's. 
New Technology IOLs (NTIOLs) that correct Presbyopia (farsighted) and Astigmatism are not covered. 
Instead, Medicare will provide a pair of eyeglasses following cataract surgery to correct these problems. 
 
The Plan covers all items that Medicare covers. Medicare rules say the presbyopia-correcting feature of an IOL 
is not covered by Medicare. 
 
While a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting 
feature of a P-C IOL. Therefore, we decided that the Plan does not have to pay for a Toric IOL provided on 
June 21, 2021.