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

 
We decided that the Plan does not have to waive the copayments for specialist office visits and wound care 
provided on August 16, 2021, to September 13, 2021. 
 
You asked the Plan to waive the copayments for specialist office visits and wound care. You say that you 
weren't informed the office visits were going to be considered outpatient hospital visits. The Plan denied your 
request. The Plan says the copayments applied are 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 $250 
copayment for each visit to a hospital outpatient surgical department and $25 copayment for each specialist 
office visit.  
 You have been asked to pay a total of $300 copayment for the two specialist office visits and wound care 
appointment. Specialist office visits fall within the Physician/Practitioner Services, Including Doctors Office 
benefit category and wound care 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 copayments for specialist office visits and wound care provided on August 16, 2021, to September 13, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 2, 2021 billed with 
codes 81206, 81210, 81235, and 81275. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 2, 2021 billed with codes 81206, 81210, 81235, and 81275.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a thoracentesis procedure performed on 
March 15, 2022. 
 
You asked the Plan to waive the copayment for the thoracentesis. You say that you feel the coding for the 
procedure may be incorrect. 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 $300 
copayment for surgical services at an ambulatory surgical center or outpatient hospital.  
 
You have been asked to pay a $300 copayment for the thoracentesis. The thoracentesis is considered a surgical 
procedure and 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 a 
thoracentesis procedure performed on March 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5226) provided by a 
participating provider. 
 
You asked the Plan to pre-approve the dental service. You say that this is medically necessary. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 17, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5226) 
provided by a participating provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service March 25, 
2022. 
 
You asked the Plan to pay for procedure code 71045. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 71045 is bundled into payment for 
code 71046. 
 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 71045 
is a column II code to column I code 71046. 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 71045 billed for date of service March 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9944). 
 
You asked the Plan to pre-approve an occlusal guard. You say that this guard should be covered due to your 
medical condition. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
occlusal guard (D9944).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you should not have to 
pay this copayment. The Plan denied your request. The Plan says you were charged this cost sharing 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 $150 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $150 for these 
services. 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 services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve post removal (D2955). 
 
You asked the Plan to pre-approve post removal. You say that you think you should be covered for this. You 
also say that it is so you can get your crown replaced and the new crown put back on. The Plan denied your 
request. The Plan says they found this service/item is not a covered benefit under your plan. 
 
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. 
 
 
 
 
 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve post 
removal (D2955).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure to treat chronic vertebrogenic pain.
You asked the Plan to pre-approve the Intracept procedure to treat chronic vertebrogenic pain. The Plan denied your request. The Plan says the Intracept procedure to treat chronic vertebrogenic pain is not medically necessary.
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 to treat chronic vertebrogenic pain. Our reviewer says that the Intracept procedure to treat chronic vertebrogenic pain is not considered medically reasonable and necessary. Our physician reviewer found that the Intracept procedure targets the basivertebral nerve for the relief of chronic vertebrogenic low back pain. Medicare guidelines consider this type of system unproven and not medically necessary. Large well-designed studies in the peer review scientific literature comparing stand-alone use of Intracept device to established surgical decompression are needed. Published studies do not demonstrate any long-term health outcome advantage with the use of Intracept as an alternative to standard surgical treatment. In this case, the review has determined that the
requested Intracept procedure is not medically reasonable or necessary. 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 to treat chronic vertebrogenic pain have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure to treat chronic vertebrogenic pain.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on 
November 23, 2021. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you should not have to pay 
this copayment because you did not have the full surgery. You were allergic to the anesthesia and could not 
continue. The Plan denied your request. The Plan says the copayment applied was correct. Because the 
anesthesia was administered, we cannot overturn the 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 $325 
copayment for in-network outpatient surgery.  
 
You have been asked to pay a $325 copayment for an outpatient surgery. An outpatient surgery falls within the 
In-Network 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 
an outpatient surgery provided on November 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a revascularization procedure of both legs for the 
enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that records do not show imaging studies that confirm the site of 
blockage to be more than 50 percent. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The documentation 
is insufficient to support a revascularization procedure of both legs. Advanced vascular imaging such as 
angiography has not identified therapeutic targets. Our physician reviewer found that the enrollee's condition 
does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a revascularization procedure of both legs for 
the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for portable oxygen equipment provided from 
December 30, 2021, to February 28, 2022. 
 
You asked the Plan to waive the coinsurance for the oxygen equipment. You say that the equipment was 
returned and had not been used since early December. 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 a 20% 
coinsurance for equipment and supplies, including oxygen equipment. 
 
 
 
 
 
 Item Allowed Amount 20% Coinsurance 
Oxygen Concentrator  December 30, 2021 $103.23 $20.65 
Portable Oxygen Device  December 30, 2021 $60.00 $12.00 
Oxygen Concentrator  January 30, 2022 $103.26 $20.65 
Portable Oxygen Device  January 30, 2022 $60.00 $12.00 
Oxygen Concentrator  February 28, 2022 $103.23 $20.65 
Portable Oxygen Device  February 28, 2022 $60.00 $12.00 
Total:  $97.95 
 
The file does not show evidence that the equipment was returned to the provider. Therefore, you have been 
asked to pay a total of $97.95, which is 20% of the allowed amount for the oxygen equipment. The oxygen 
equipment 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 portable oxygen equipment provided from December 30, 
2021, to February 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital and laboratory services rendered on 
January 11, 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 an OPPS payment status indicator is assigned to every 
HCPCS code. 
 
We looked at the file and Medicare rules. Billed procedure code G0463 is not covered billed with a T or S 
procedure, and the file shows that code 88184 is an S procedure. Therefore, we decided that the Plan does not 
have to pay for the outpatient hospital and laboratory services rendered on January 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation/general anesthesia services (D9222 and 
D9223). 
 
You asked the Plan to pre-approve the deep sedation/general anesthesia services. You say that you tried having 
your teeth removed without anesthesia, but you were in such pain that the dentist could not remove the teeth. 
The Plan denied your request. The Plan says these services are not covered under your benefit package. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve deep 
sedation/general anesthesia services (D9222 and D9223).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis services to be provided by the requested  
out-of-network provider. 
 
You asked the Plan to pre-approve dialysis services to be provided by the requested out-of-network provider. 
You say that this facility is near your home and you could walk to this facility if you had any issues with 
transportation. The Plan denied your request. The Plan says you must receive your care from a network 
provider. In most cases, care you receive from an out-of-network provider (a provider who is not part of our 
plans network) will not be covered. 
 
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 dialysis 
services to be provided by the requested out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methotrexate tablets. 
 
You asked the Plan to pre-approve Methotrexate tablets. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says Methotrexate tablets are not covered under the 
enrollee's Medicare Part B 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 Methotrexate tablets.  
 
 Benefits for Methotrexate tablets 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and copayment for a fine needle aspiration 
biopsy performed on February 23, 2022. 
 
You asked the Plan to waive the deductible and copayment for the needle aspiration biopsy. You say that the 
procedure was unsuccessful. The Plan denied your request. The Plan says the correct deductible and copayment 
were applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $1,000 deductible which applies to certain items and services.  
 
The needle aspiration biopsy falls within the Outpatient Surgery, Including Services Provided at Hospital 
Outpatient Facilities and Ambulatory Surgical Centers benefit category. The Plan has followed Medicare rules 
by clearly disclosing in the contract that there is $1,000 deductible which applies to certain items and services. 
This cost sharing is a contractual obligation that had not been met at the time the needle aspiration biopsy was 
received on February 23, 2022.  The file shows that at the time of the procedure, you had met $0 for your deductible. Once this amount was 
applied, the remaining $24.42 was applied for the copayment amount, which is less than the $275 copayment 
for the needle aspiration biopsy. Therefore, we decided that the Plan does not have to waive the deductible and 
copayment for a fine needle aspiration biopsy performed on February 23, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for in-person physical therapy provided on 
March 24, 2022. 
 
You asked the Plan to waive the copayment for in-person physical therapy. You say that you cannot afford this 
copayment and would like it waived. The Plan denied your request. The Plan says the copayment applied was 
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 $30 
copayment for outpatient rehabilitation services.  
 
 
 
 
 
 
 You have been asked to pay a $30 copayment for in-person physical therapy. In-person 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 in-person physical therapy provided on March 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on April 
25, 2022. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that you were informed there was 
no cost if the appointment was within 90 days of surgery. 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 $30 
copayment for specialist visits.  
 
You have been asked to pay a $30 copayment for the specialist visit. The specialist visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits 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 specialist office visit provided on April 25, 2022.