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

 
We decided that the Plan does not have to waive the coinsurance for a compound injection eye drug (J7999) 
provided on December 7, 2021. 
 
You asked the Plan to waive the coinsurance for a compound injection eye drug. You say that you would like 
to know that between the two billing codes, why is one requiring more tracking information and why does that 
double the amount approved by the Plan, the amount the Plan is paying, and the amount you are paying. You 
also say that you are getting the exact same drug at both visits. The Plan denied your request. The Plan says 
you were charged the correct cost sharing amount, and the code for the eye injection had c hanged due to recall 
issues. 
 
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 Part B prescription drugs.  
 
You have been asked to pay $31.20 in coinsurance, which is 20% of the allowed amount for a compound 
injection eye drug ($156 allowed amount x 20% coinsurance = $31.20). Compound injection eye drugs fall 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 a compound injection eye drug (J7999) provided on December 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient procedure performed on 
March 1, 2021. 
 
You asked the Plan to waive the copayment for the outpatient procedure. You say that you already paid the 
coinsurance and feel it is unfair to charge more. 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 $325 
copayment for surgery or other services provided at an outpatient hospital.  
 
You have been asked to pay a $325 copayment for the outpatient procedure. The outpatient procedure 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 an outpatient 
procedure performed on March 1, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
November 27, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you believe your medical bills should 
be covered in full. 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 $90 
copayment for each emergency room visit.  
 
You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the Emergency Care 
benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for an emergency room (ER) visit 
provided on November 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for wound care services provided from 
September 20, 2021, to October 21, 2021. 
 
You asked the Plan to waive the copayments for the wound care services. You say that you never spent more 
than 20 minutes in the wound center and the amount charged is crazy. 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 $100 
copayment for each outpatient hospital surgery service.  
 
The file shows you had a total of 5 wound care visits from September 20, 2021, to October 21, 2021. You have 
been asked to pay a $100 copayment for each of the wound care services. The total for all visits is $500 ($100 copayment x 5 visits = $500). The wound care services fall 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 wound care services provided from September 20, 2021, to October 
21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0482) provided on November 17, 2021, by an 
out-of-network provider. 
 
You asked the Plan to pay for drug testing. 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 drug testing (G0482) provided on November 17, 
2021, by an out-of-network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services (90834) provided on November 15, 
2021, by an out-of-network provider. 
 
You asked the Plan to pay for psychotherapy services. You say that the services at issue were a necessity for 
the enrollee's care. 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 psychotherapy services (90834) provided on 
November 15, 2021, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (ECG) provided on 
October 25, 2021. 
 
You asked the Plan to waive the copayment for the ECG. You say that you never had a copayment for this 
procedure before. 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 non-radiological diagnostic services, including ECG's.  
 
You have been asked to pay $15.56, which is less than the $30 copayment for the ECG. The ECG 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 an electrocardiogram (ECG) provided on October 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home visit to be provided by an out-of-network 
(OON) podiatrist. 
 
You asked the Plan to pre-approve a home visit. You say that you have been trying to find an in-network doctor 
who can perform these services in your home for two years. The Plan denied your request. The Plan says there 
are providers in-network who can perform these services in your home if you cannot go to a clinic. 
 
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 home visit to be provided by an out-of-network (OON) podiatrist.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on September 18 to October 
15, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for home health services. 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 home health services provided on September 18 to 
October 15, 2021, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 15, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on June 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 14, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent or urgent and prior authorization was not obtained to provide out-of-network 
care. 
 
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 the laboratory services provided on June 14, 2021, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6545. 
 
You asked the Plan to pre-approve the compression stockings. You say that the stockings are 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 compression stockings described by code A6545 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means 
that the enrollee does not have a medical condition for which compression stockings can be covered or paid for 
by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings 
identified with code A6545.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve scaling and root planing (D4342) for the upper left and 
upper right quadrants. 
 
You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied 
your request. The Plan says the requested services are not covered for implants. 
 
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 the dental 
services when the services are medically necessary and reasonable.   
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 dental services. Our reviewer says 
that the requested scaling and root planing for the upper left and upper right quadrants does not meet the 
criteria for coverage. Our physician reviewer found the requested code, D4342, is to be used for scaling of 
natural tooth structure, cementum and dentin, on periodontally compromised teeth. In this instance, there are no 
natural teeth with root surfaces to be scaled. Given there are no natural teeth in the upper arch, the requested 
codes are not appropriate for the care needed and do not meet the criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve scaling and root planing (D4342) for the upper left and upper right quadrants.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a High Frequency Chest Wall Oscillation Device. 
 
You asked the Plan to pre-approve the High Frequency Chest Wall Oscillation Device. You say that this device 
is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that this device is covered when records show you have 
failed standard treatment to remove mucus and liquid. 
 
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 High Frequency Chest Wall 
Oscillation Device. Our reviewer says that this device is not medically necessary. Our physician reviewer 
found the patient has bronchiectasis and pulmonary infection. Airway clearance is an important part of 
treatment for this condition; however, Medicare requires documentation that other methods for airway 
clearance have been tried and failed. There is no evidence the patient has tried a flutter valve or similar device. 
 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 High Frequency Chest Wall Oscillation Device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a High Frequency Chest Wall Oscillation 
Device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options. 
 
You asked the Plan to pre-approve a group 3 power wheelchair with multiple power options. You say that this 
wheelchair is medically reasonable and necessary. The Plan denied your request. The Plan says it is not 
medically reasonable for the enrollee to receive this specific wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 wheelchair with multiple power options is 
subject to the criteria listed 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 a group 3 power wheelchair with 
multiple power options. Our reviewer says that the requested group 3 power wheelchair with multiple power 
options is not medically reasonable and necessary according to Medicare rules. Our physician reviewer found 
the enrollee is a 39-year-old female with a past medical history of a stroke and end stage renal disease who 
requires a power wheelchair for mobility. Based on the medical records provided there is no documentation 
that the patient meets coverage criteria for a group 3 power wheelchair with multiple power options. Records 
do not document that the patient is at high risk for skin breakdown or requires bladder catherization or has 
lower extremity spasticity to meet criteria for the power tilt and recline feature. Thus, the enrollee does not 
meet the coverage criteria for a wheelchair with multiple power options. As the enrollee does not satisfy 
coverage criteria for the group 3 power wheelchair with multiple power options base, the subsequent 
accessories will not be covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a group 3 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple 
power options.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasonic guidance for radiation services to be provided 
on a daily basis. 
 
You asked the Plan to pre-approve ultrasonic guidance. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says each individual radiation treatment given 
does not require ultrasound imaging. 
 
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 ultrasonic guidance. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found using ultrasound services on a daily basis is not unreasonable, but to bill for daily 
simple simulations or image-guided radiation therapy (IGRT) for a technology for which need has not been 
established by published data or supported by consensus guidelines (many of which recommend against 
treatment with these devices in general- citations) is not medically necessary. Billing for daily simulations or 
IGRT would not be furnished in accordance with accepted standards of medical practice."  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasonic guidance have not been met. Therefore, we decided that the Plan does 
not have to pre-approve ultrasonic guidance for radiation services to be provided on a daily basis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Coronavirus vaccine provided on June 2, 2021. 
 
You asked the Plan to pay for Coronavirus vaccine. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered by the Plan. 
 
The Coronavirus vaccine is to be billed directly to Original Medicare by the rendering pharmacy or physician's 
office. The Plan follows the same rules. Please submit this claim to Original Medicare for payment 
consideration. Therefore, we decided that the Plan does not have to pay for the Coronavirus vaccine provided 
on June 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the IV tubing extension set (S1015) and the infection control 
supplies (S8301) provided on September 3, 2021. 
 
You asked the Plan to pay for codes S1015 and S8301. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered 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 looked at the file and Medicare rules. In this case, CPT codes S1015 and S8301 have a status code of "I" 
under the Medicare Physicians Fee Schedule Database (MPFSDB) and are not valid for Medicare purposes. 
Medicare uses other codes for reporting of, and payment for, these services. Therefore, we decided that the Plan does not have to pay for the IV tubing extension set (S1015) and the 
infection control supplies (S8301) provided on September 3, 2021.