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

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that facet joint injections are medically 
necessary. The Plan denied your request. The Plan says facet joint injections do not meet the Medicare LCD 
coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 facet joint injections. Our reviewer says 
that facet joint injections are not medically necessary. Our physician reviewer found that the L5-S1 disc is a 
probable pain generator and this is also the site of prior surgery. The enrollee does not meet the LCD criteria on 
the basis these two issues. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a subsequent nursing facility care visit provided on February 
11, 2022, by an OON provider. 
 
You asked the Plan to pay for a subsequent nursing facility care visit. You say that the doctor is a hospitalist 
physician and depends on the hospital staff to verify eligibility and to obtain proper authorization from the 
enrollee's Plan. The Plan denied your request. The Plan says the out-of-network services were not authorized. 
 
 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 subsequent nursing facility care visit provided 
on February 11, 2022, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lancets rendered on January 30, 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 more than one spring powered device (code A4258) 
per 6 months is not reasonable and necessary.  
 
We looked at the file and Medicare rules. The file shows that a previous claim for these services was processed 
and paid on November 30, 2021. The services on January 30, 2022 were rendered fewer than six months from 
the previously covered claim. Therefore, we decided that the Plan does not have to pay for the lancets rendered 
on January 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care services coded 99232 provided 
on January 12, 2022. 
 
You asked the Plan to pay for the subsequent hospital care services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not supported by the 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. 
 
In this case, the CPT Code Manual definition of code 99232 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; Medical decision making of 
moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor 
complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
We find that CPT code 99232 is not supported in the medical record. Specifically, there is no documentation 
submitted to support code 99232 for this date of service. Based on this information, we decided that Medicare 
rules for coverage of the subsequent hospital care services have not been met. Therefore, we decided that the 
Plan does not have to pay for the subsequent hospital care services coded 99232 provided on January 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 13, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 an office visit provided on January 13, 2022, by an 
out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on March 22, 2022. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you cannot afford to do these shots 
every three months and you need them covered. The Plan denied your request. The Plan says the coinsurance 
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 Medicare covered Part B drug.  
 
You have been asked to pay $311.33 which is 20% of the allowed amount for an injection. The allowed amount 
is $1,556.64 (20% x $1,556.64= $311.33). an injection falls within the Medicare Part B Prescription Drugs 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the coinsurance for an injection provided on March 
22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 23, 2021. 
 
You asked the Plan to pay for the services provided. You say that drug testing is needed to monitor possible 
Opioid abuse. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 We looked at the file and Medicare rules. We find that the testing described by billed code 83789 is considered 
specimen validity testing which is not separately payable. 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 lab services provided on November 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye services or procedures (92499) and special service, 
procedure or report (99199) provided on January 3, 2022. 
 
You asked the Plan to pay for the eye services or procedures and special service, procedure or report. You say 
that you are supposed to get $70 ever two years for eyeglasses. The Plan denied your request. The Plan says 
you used your eyewear benefit less than 24 months ago. 
 
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. The Plan covers up to $70 once every 24 months toward the cost of eyewear. 
 
We looked at the file and the Plan's rules. The record shows that you exhausted your $70 eyewear allowance on 
October 2, 2020. Based on this information, we decided that the Plan's rules for coverage of the eye services or 
procedures and special service, procedure or report have not been met. Therefore, we decided that the Plan does 
not have to pay for the eye services or procedures (92499) and special service, procedure or report (99199) 
provided on January 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for fluoroscopic guidance for needle biopsy 
provided on June 24, 2021. 
 
You asked the Plan to waive the copayment for the fluoroscopic guidance. You say that the cost sharing 
amounts are inconsistent. 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 $115 
copayment for radiological diagnostic services.  
 
You have been asked to pay $113.91, which is less than the $115 copayment for the fluoroscopic guidance. The 
fluoroscopic guidance 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 fluoroscopic guidance for needle 
biopsy provided on June 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthrocentesis provided on February 17, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for arthrocentesis. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 arthrocentesis provided on February 17, 2022, by 
an out-of-network (OON) provider.
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 
July 5, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that a visiting nurse advised you to go the 
the hospital or you could die. 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 July 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for knee injections provided on March 18, 
2022. 
 
You asked the Plan to waive the coinsurance for knee injections. You say that this amount sounds too high and 
there might be an error. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for in-network Part B prescription drugs. The allowed amount of this item is $2067.60 resulting in 
a coinsurance amount of $413.52 ($2067.60 x 20% = $413.52). 
 
You have been asked to pay a $413.52 coinsurance for knee injections. Knee injections falls within the 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 knee injections 
provided on March 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network services provided to the enrollee on August 
25, 2022. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for 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 must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the 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 out of network services provided to the enrollee on 
August 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for echocardiography (EKG) on April 12, 
2022. 
 
You asked the Plan to waive the coinsurance for echocardiography (EKG). You say that this is the second time 
you are being billed in error. The Plan denied your request. The Plan says the cost sharing you are being 
charged 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 of the cost for Medicare-covered diagnostic procedures and tests. Covered services include but are 
not limited to other outpatient diagnostic tests. The provider billed in the amount of $299 and the allowed 
amount is $68.37. The Plan paid $54.70. $68.37 - $54.70 = $13.67. Therefore, results in the total cost sharing 
amount of $13.67. 
 
 
 You have been asked to pay a 20% coinsurance for echocardiography (EKG). Echocardiography (EKG) falls 
within the Outpatient diagnostic test 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 coinsurance for echocardiography (EKG) on April 12, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided January 2, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that you were unaware this was a non-covered 
service. The Plan denied your request. The Plan says this service is not covered when there is no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 The ambulance company did not provide transport services on January 2, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided January 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive lens (V2781) and scratch resistant coating 
(V2760) provided on April 5, 2022. 
 
You asked the Plan to pay for the progressive lens and scratch resistant coating. You say that you contacted the 
Plan and looked online to see if an optometrist appointment would be covered, and you were told it would be. 
The Plan denied your request. The Plan says you were appropriately charged for the enhanced services not 
covered under your vision benefit. The Plan also says that the records confirm you received a discounted rate 
for the enhanced services. 
 
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. Enhancements are not covered through the allowance but may be 
purchased at an additional cost. Based on this information, we decided that the Plan's rules for coverage of the 
progressive lens and scratch resistant coating have not been met. Therefore, we decided that the Plan does not 
have to pay for the progressive lens (V2781) and scratch resistant coating (V2760) provided on April 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 8, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One (J7326). 
 
You asked the Plan to pre-approve Gel-One. You say that Gel-One is medically necessary. The Plan denied 
your request. The Plan says a trial of Orthovisc, Synvisc, or Synvisc One is required before alternatives can be 
considered. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Gel-One. Our reviewer says that Gel-
One is not medically necessary. Our physician reviewer found the records show no trial of the plan preferred 
drugs or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One (J7326).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on 
January 6, 2022. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for 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 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 out of network medical services provided to the 
enrollee on January 6, 2022.