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

 
We decided that the Plan does not have to pay for the services (99100, 99140) provided on September 7, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are 
bundled. 
 
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee 
Schedule indicates that payment for covered services is always bundled into payment for other services not 
specified.  
 
We looked at the file and Medicare rules. Code 99100 99140 are assigned a status indicator of B under the 
Physician Fee Schedule, which means that these are bundled services. Payment for these services is bundled 
into payment for other services. No separate payment can be made for ode 99100 and 99140. 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 services (99100, 99140) provided on September 7, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the Radiologic examination (71045) provided on September 19, 2021. 
 
You asked the Plan to pay for code 71045. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that there were two separate chest 
x-rays taken on September 19, 2021, and the Plan paid for only one chest x-ray. Therefore, we decided that the 
Plan has to pay for the Radiologic examination (71045) provided on September 19, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray (71045) provided September 20, 2021. 
 
You asked the Plan to pay for the x-ray. You say that this service was 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 code 71045 is not supported in the medical record. Specifically, one unit of this service was 
already paid. Additional units are not supported. Based on this information, we decided that Medicare rules for 
coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray 
(71045) provided September 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the foot inserts you received on August 6, 
2021. 
 
You asked the Plan to waive the coinsurance for the foot inserts. You say that you do not want to pay the 
coinsurance because you have not used these inserts at all.  You said that you would like to return them. The 
Plan denied your request. The Plan says you were charged this coinsurance 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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay 20% coinsurance for the foot inserts. The foot inserts fall within the durable 
medical equipment 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 the foot inserts you 
received on August 6, 2021.  
 Your complaint about being able to return these inserts 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: Favorable

 
We decided that the Plan has to pay for an office visit (99214) provided on October 26, 2021. 
 
You asked the Plan to pay for an office visit. You say that the enrollee's automobile accident was more than a 
year ago and services have since been covered by the Plan. The Plan denied your request. The Plan says that 
the necessary information from the primary insurance has not been received. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has not met its obligation with regards to coordination of benefits. Specifically, the Plan has not 
directed you to bill the primary insurer or sent the bill to the primary insurer directly. The Plan has indicated 
they are only requesting information from the enrollee. Therefore, we decided that the Plan has to pay for an 
office visit (99214) provided on October 26, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the pelvic ultrasound you had on June 22, 
2021, and the transrectal ultrasound you had on July 22, 2021. 
 
You asked the Plan to waive the coinsurance for the two ultrasounds. You say that these copayments should be 
covered under your regular doctor copayment because these were follow-up services. The Plan denied your 
request. The Plan says you were charged this coinsurance 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 20% 
coinsurance up to $75 for diagnostic radiology services.  
 
 
 You have been asked to pay 20% coinsurance up to $75 for the two ultrasounds. The two ultrasounds fall 
within the diagnostic radiology services benefit category. This cost sharing is separate from any cost sharing 
for an office visit and applies regardless of the reason for the radiology 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 coinsurance for the pelvic ultrasound you had on June 22, 2021, and the transrectal ultrasound you 
had on July 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Vitamin B12 injection you received on 
June 10, 2021. 
 
You asked the Plan to waive the coinsurance for the Vitamin B12 injection. You say that you are confused by 
the bill because the Plan originally paid the claim and then took the money back. The Plan denied your request. 
The Plan says you were charged this coinsurance correctly.  The Plan says that your share for this injection is 
$.35. 
 
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 drugs.  
 
You have been asked to pay 20% coinsurance for the Vitamin B12 injection. The Vitamin B12 injection falls 
within the Medicare Part B 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 
the Vitamin B12 injection you received on June 10, 2021.  Your complaint about the Plan taking payment back is not a valid appeal for medical coverage.  It appears as 
though that is a dispute between this network provider and the Plan. 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 the Transversus abdominis plane (TAP) block (64488) 
provided on April 19, 2021. 
 You asked the Plan to pay for code 64488. 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. In this case, we have confirmed that code 64488 
is a column II code to column I code 43775. 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 the Transversus abdominis plane (TAP) block (64488) provided 
on April 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the facetectomy procedures provided on September 21, 2021, 
billed with codes 63047 and 63048. 
 
You asked the Plan to pay for the facetectomy procedures as billed. You say that these services were provided 
separately from the spinal fusion services. Medical guidelines allow for reimbursement of all codes. The Plan 
denied your request. The Plan says this is not separately payable since these were provided at the same levels 
as the fusion. 
 
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 63047 
is a column II code to column I code 22633. This claim has not been billed with an appropriate modifier to 
bypass the edit. In addition, code 63048 cannot be paid as it is an add-on code to 63047. Since the primary code 
is denied, the add-on code cannot be paid. Based on the claim submitted, Medicare billing criteria have not 
been met. Therefore, we decided that the Plan does not have to pay for the facetectomy procedures provided on 
September 21, 2021, billed with codes 63047 and 63048.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (29873) provided September 29, 2021. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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, the CPT Code Manual definition of code 29873 is Arthroscopy, knee, surgical with later release. 
 
 
 
 
 We find that CPT code 29873 is not supported in the medical record. Specifically, no description of the 
procedure was documented to confirm this service was performed. Based on this information, we decided that 
Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan 
does not have to pay for surgical services (29873) provided September 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the services you received with an out-of-
network oncologist on July 29, 2021. 
 
You asked the Plan to waive the deductible for the out-of-network oncology services. You say that you believe 
this provider is in-network. The Plan denied your request. The Plan says the provider you used is not a network 
provider with the Plan.  The Plan says that you had not yet satisfied your out-of-network deductible at the time 
of these services. 
 
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 a $750 deductible which applies to out-of-network services.  
 
We searched the Plan's online provider directory.  The directory confirms that the provider you saw is not in-
network with your Plan. The Plan has followed Medicare rules by clearly disclosing in the contract that there is 
a $750 deductible which applies to out-of-network services. This cost sharing is a contractual obligation that 
had not been met at the time the out-of-network oncology services were received on July 29, 2021.  Therefore, we decided that the Plan does not have to waive the deductible for the services you received with an 
out-of-network oncologist on July 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the specialty absorptive dressing, wound 
cover (A6253) and the sterile gauze (A6402) provided on November 9, 2021. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the items 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). The enrollees contract with the Plan clearly says that he must pay a 
20% coinsurance for durable medical equipment and related supplies.  
 
 
 The enrollee has been asked to pay $45.78 (Plan allowed amount of $228.90 x 20% coinsurance) for the 
durable medical supplies provided. This means that he has been asked to pay the correct amount based on the 
contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when he enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the specialty 
absorptive dressing, wound cover (A6253) and the sterile gauze (A6402) provided on November 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received from September 28, 2021, 
to September 30, 2021. 
 
You asked the Plan to pay for the drugs. You say that you were classified as outpatient and charged for 
medication that you were not provided. The Plan denied your request. The Plan says this is not a covered 
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 pay for self-administered drugs received 
from September 28, 2021, to September 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a patient lift. 
 
You asked the Plan to pre-approve the patient lift. You say that it is felt that this should be covered for use after 
hip surgery. The Plan denied your request. The Plan says the criteria for this device have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that patient lifts are covered only when the patient would 
be bed-confined without the use of the lift. 
 
 
  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 patient lift. Our reviewer says that 
the documentation does not support that Medicare criteria for the lift are met. Our physician reviewer found the 
documentation does not support that the member requires a mechanical lift for transfers or that he would be bed 
bound without a mechanical lift. He is able to move all of his extremities. Furthermore, the documentation 
indicates the member would only use the lift post-operatively. 
 
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 patient lift have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a patient lift.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Xiaflex injections you received on 
October 7, 2021, to October 8, 2021. 
 
You asked the Plan to waive the coinsurance for the Xiaflex injections. You say that you called and confirmed 
coverage of these services and they should be covered regardless of where the services are given. The Plan 
denied your request. The Plan says it has waived the copayment assessed for the hospital service on this date, 
but that you are still responsible for the coinsurance for the drug. 
 
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 drugs.  
 
 
 
 
 You have been asked to pay 20% coinsurance for the Xiaflex injections. The Xiaflex injections fall within the 
Medicare Part B 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 the Xiaflex 
injections you received on October 7, 2021, to October 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walk-in tub purchased on August 18, 2021. 
 You asked the Plan to pay for this equipment. You say that no one told you this tub would not be covered but 
that you and the doctor should write letters as to why it was needed. The Plan denied your request. The Plan 
says a walk-in commercial tub is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules are specific that hygienic (shower or bath) equipment is not covered. The rules are 
specific that only Medicare approved durable medical equipment providers can be used for any type of 
equipment purchases.  
 
You purchased a walk-in tub from a commercial retail provider. You did not have prior authorization and the 
equipment purchased is not covered by the Plan or by Medicare. This equipment does not serve a purpose that 
is primarily medical in nature. This item is available to the general public and would be helpful even to those 
who are not sick or injured. Therefore, we decided that the Plan does not have to pay for a walk-in tub 
purchased on August 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the wound debridement services (97597) 
provided on September 2, 2021 and September 23, 2021. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have 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 a $260 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay $358.16 ($179.08 x 2) for the Medicare-covered surgeries provided at an 
outpatient hospital. This is the Plans allowed amount for these services which is less than the applicable 
copayments. 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 the wound debridement services (97597) 
provided on September 2, 2021 and September 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the expandable controller and related electronic 
connections and harness to be provided with an approved power wheelchair. 
 
You asked the Plan to pre-approve the expandable controller and related components. You say that it is felt that 
the request should be approved in full. The Plan denied your request. The Plan says the expandable controller 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 expandable controller and related 
components. Our reviewer says that the requested items are not considered medically reasonable and necessary 
in this case.  
 Our physician reviewer found based on the medical records provided, there is no documentation that the 
requested controller, harness and electronic connection meet Medicare criteria for medically 
necessary. Provided records document that the enrollee has 4/5 left upper extremity wrist and hand strength 
thus indicating she has adequate upper extremity strength to operate the wheelchairs power options with their 
own switches. 
 
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 expandable controller and related components have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the expandable controller and related electronic 
connections and harness to be provided with an approved power wheelchair.