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

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the physical therapy. You say that you did not progress with your previous 
physical therapy. You say you need therapy at a closer facility and a pelvic health specialist. The Plan denied 
your request. The Plan says the provider is 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the removal of impacted ear wax (69210) 
provided on August 11, 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 $40 
copayment for physician specialist services (including surgery second opinion, Medicare-covered telehealth or 
urgently needed services).  
 You have been asked to pay a $40 copayment for the physician specialist service provided. 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 removal of impacted ear wax (69210) provided on August 11, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81291, 81479) provided on June 23, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the original denial was based on a lack of 
medical necessity and the reconsideration must be performed by a physician with expertise in the field of 
medicine that is appropriate for the services at issue. You also say that you would like the Plan to reconsider 
the original determination and cover the services as medically necessary. The Plan denied your request. The 
Plan says that this service was denied due to no authorization obtained and that these tests can be performed by 
an in-network provider. The Plan also says that medical necessity has not been established for services to be 
rendered by a non-participating provider. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 laboratory services (81291, 81479) provided on 
June 23, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a debridement of nails (11720) provided on June 8, 2021, by 
an out-of-network provider. 
 
You asked the Plan to pay for a debridement of nails. You say that the service at issue was a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment for out-of-network care have 
not been met. 
 
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 debridement of nails (11720) provided on June 
8, 2021, by an out-of-network provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for genetic testing (0037U) provided October 7, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that there are no in-network providers that offer this 
type of testing. The service was ordered by an in-network physician. The Plan denied your request. The Plan 
says that there were network providers available. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the genetic testing by a contract provider. The file does not show that the plan 
provided notice that the genetic testing would not be covered. Under Medicare rules, this means the genetic 
testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for genetic testing 
(0037U) provided October 7, 2021.  
 
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 a physician office visit (99214) and an electrocardiogram 
procedure (93000) provided on July 20, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for a physician office visit and an electrocardiogram. You say that the services at 
issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment 
for out-of-network care have not been met. 
 
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 physician office visit (99214) and an 
electrocardiogram procedure (93000) provided on July 20, 2021, by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a pacemaker replacement procedure 
performed on September 17, 2021. 
 
You asked the Plan to waive the coinsurance for the pacemaker replacement. You say that the provider was in 
network and the cost share should not be that high. 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 surgery performed at an outpatient hospital facility.  
 
You have been asked to pay $3,498.25, which is 20% of the allowed amount for the pacemaker replacement 
($17,491.23 allowed amount x 20% coinsurance = $3,498.25). Please note that this coinsurance is the in-network rate for procedures at an outpatient hospital. The pacemaker replacement 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 coinsurance for a pacemaker replacement procedure performed 
on September 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a contraceptive device placement (J7298, 58300) provided 
November 2, 2021. 
 
You asked the Plan to pay for the contraceptive device placement. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the billed code is not covered by Medicare under any 
circumstance. 
 
The Plan must follow Medicare rules. Medicare rules say that when used for a diagnosis of Endometrial cancer, 
this service must be billed using code 58999 along with an appropriate diagnosis code. 
 
We looked at the file and Medicare rules. The service was billed using code 58300 and not the required code 
58999 which can be covered if billed with an appropriate diagnosis code. Based on this information, we 
decided that Medicare rules for coverage of the contraceptive device placement have not been met. Therefore, 
we decided that the Plan does not have to pay for a contraceptive device placement (J7298, 58300) provided 
November 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for eyeglasses provided on 
November 29, 2021. 
 
You asked the Plan to pay an additional amount for the eyeglasses. The Plan denied your request. The Plan 
says the claim processed correctly. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
 
We looked at the file and the Plan's rules. The file shows that the Plan previously paid $165 for eyewear 
provided on January 9, 2021. Therefore, we decided that the Plan does not have to pay an additional amount for 
eyeglasses provided on November 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) 
(72158) provided on March 22, 2021. 
 
You asked the Plan to waive the copayment for the MRI. You say that the services should be covered as you 
were not aware of the cost beforehand and were under the impression that the plan pays 100%. 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.  
 
 
  You have been asked to pay a $150 copayment for an MRI. MRIs 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 
magnetic resonance imaging (MRI) (72158) provided on March 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections (67028, J0178) provided October 18, 2021. 
 
You asked the Plan to pay for the injections. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as 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. 
 
We find that CPT codes 67028 and J0178 are not supported in the medical record. Specifically, the codes were 
billed with individual left and right laterality modifiers when a bilateral modifier exists for this service. Based 
on this information, we decided that Medicare rules for coverage of the injections have not been met. 
Therefore, we decided that the Plan does not have to pay for injections (67028, J0178) provided October 18, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the Denosumab injection provided by a 
hospital on September 30, 2021. 
 
You asked the Plan to waive the cost sharing for the Denosumab injection. You submitted your bill for 
reimbursement. The Plan denied your request. The Plan says the cost sharing 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 each Medicare-covered Part B drug. The allowed amount of this drug is $1258.32.  
 
Your contract with the Plan also says that you must pay a $275 copayment for Medicare-covered surgery or 
other services provided to you at an outpatient hospital.  
 
You have been asked to pay $251.66 coinsurance ($1258.32 x 20%) for the Denosumab and a $63.75 
copayment for the injection service. The Denosumab falls within the Medicare Part B Prescription Drugs 
benefit category. You have also been asked to pay $63.75 for the injection, which is less than the $275 
copayment. The injection falls within the Outpatient Surgery and Other Medical 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 ($251.66 + $63.75 = $315.41). 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 cost sharing for the Denosumab injection provided by a hospital on September 30, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an arthroplasty (27130) and physical 
therapy visit (97162) provided on April 26, 2021, and April 27, 2021. 
 
You asked the Plan to waive the copayment for the arthroplasty and physical therapy visit. You say that the 
services should be covered. The Plan denied your request. The Plan says the copayments 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 $225 
copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers and a $20 copayment for Outpatient rehabilitation services 
 You have been asked to pay a $225 copayment for an arthroplasty and a $20 copayment for physical therapy 
services. The arthroplasty falls within the Outpatient surgery, including services provided at hospital outpatient 
facilities and ambulatory surgical centers benefit category and physical therapy services fall 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 
an arthroplasty (27130) and physical therapy visit (97162) provided on April 26, 2021, and April 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a wrist hand finger orthosis (L3809) 
provided on November 1, 2021. 
 
You asked the Plan to waive the coinsurance for the wrist hand finger orthosis. You say that the services should 
be covered. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for Durable medical equipment (DME) and related supplies.  
 
 
  You have been asked to pay a 20% coinsurance for the wrist hand finger orthosis (allowed is $167.23 x 20% = 
$33.5). Wrist hand finger 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 waive the coinsurance for a wrist hand finger orthosis 
(L3809) provided on November 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the intravitreal injection of a pharmacologic 
agent (67028) and the unclassified drug injection (J3490) provided on June 10, 2019. 
 
You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to 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 20% of the cost for Part B covered chemotherapy 
drugs and other Part B covered drugs. Additionally, enrollees must pay a $15 copayment for routine vision and 
diagnostic exams.   
 
You have been asked to pay $3,352.20. This includes the Plans allowed amount of $16,686 x 20% 
coinsurance= $3,337.20 for the Medicare-covered Part B drug injection provided. Additionally, this amount 
includes a $15 copayment for the intravitreal drug injection provided during the ophthalmological medical 
examination. 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 cost share for the intravitreal injection of a pharmacologic 
agent (67028) and the unclassified drug injection (J3490) provided on June 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth physician visit (99214) provided on October 6, 
2021, by an out-of-network provider. 
 
You asked the Plan to pay for a telehealth physician visit. You say that the service at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for out-of-network 
care have not been met. 
 
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 telehealth physician visit (99214) provided on 
October 6, 2021, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the angiography provided to the enrollee on July 13, 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 code was not substantiated by the clinical documentation. 
 
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 asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the procedure report does not include 
documentation to support an angiography, extremity, unilateral radiological supervision and interpretation has 
been performed. To cite the report "Attention was then turned toward the arterial inflow. Selective 
catheterization of the radial artery was performed, and an arteriogram obtained. This was done to evaluate for 
inflow stenosis."   
 
 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the angiography provided to the enrollee on July 13, 2021