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

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services provided 
on November 2, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you would like the 
copayment waived due to your current situation. 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 $350 
per trip for ambulance services.  
 
You have been asked to pay a $350 for the ambulance transportation. The ambulance transportation falls within 
the Ambulance 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 ambulance 
transportation services provided on November 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an advanced foot ankle feature, prosthetic leg, and other 
parts (L5968, L5981) for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says a request for replacement K3 foot does not meet Medicare criteria as reasonable and 
necessary, as Medicare does not cover replacements for items that are still under warranty. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not consistently reveal that the enrollee demands prosthetic utilization beyond 
simple locomotion at a K3 level. The enrollee's current advanced foot and ankle feature (L5968 and L5981) are 
under three years old and do not meet Medicare criteria for replacement at this time. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an advanced foot ankle feature, prosthetic leg, and other parts (L5968, L5981) for the 
enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ophthalmological services: medical 
examination and evaluation, with initiation or continuation of diagnostic and treatment program (92014) 
provided November 10, 2021. 
 
You asked the Plan to waive the copayment for the eye exam. You say that your eye exam was routine and you 
don't feel you should be responsible for a copayment. The Plan denied your request. The Plan says the 
copayment has been applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for an eye exam to diagnose and treat diseases and conditions of the eye.  
 
You have been asked to pay a $20 copayment for the eye exam. The medical records show that this exam was a 
cataract check. The medical eye exam falls within the Vision 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 the ophthalmological services: medical examination and evaluation, 
with initiation or continuation of diagnostic and treatment program (92014) provided November 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an onabotulinumtoxina (Botox) injection 
provided on September 30, 2021. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you feel it is unfair for people on 
social security to receive such a large bill. 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 Part B non-chemotherapy drugs.  
 
You have been asked to pay $865.44, which is 20% of the allowed amount for the injection ($4,327.20 allowed 
amount x 20% coinsurance = $865.44). The 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 onabotulinumtoxina (Botox) 
injection provided on September 30, 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 
August 19, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you feel you should not have a 
copayment since the visit was COVID-19 related. 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 care visit.  
 
The file shows that the Plans cost share waivers for COVID-19 ended on May 31, 2021. Therefore, 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 
August 19, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing 
and/or skilled therapy services on a daily basis. The enrollee does not have any parental medication; complex 
wound care or nutrition given via a feeding tube. She is medically stable without any acute exacerbations of 
chronic medical problems. Her physical function is at or near her baseline and she can receive services at a 
lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation (A0427, A0425) provided on 
November 21, 2020. 
 
You asked the Plan to pay for the ambulance transport. You say that these claims were initially filed in a timely 
manner with no response from the insurance company. You included a screenshot to show the original 
submission date. The Plan denied your request. The Plan says this claim was received more than one year after 
the date of service. The documentation provided is not sufficient to prove timely filing as the payer listed is not 
the Plan, and the document is from the providers billing system. There is no evidence that this claim was 
received by the Plan in a timely manner, or that the provider was given notice that the claim was received. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the ambulance transport was not filed until December 14, 2021. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the ambulance transportation (A0427, A0425) provided on 
November 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the porcelain crown (D2740) provided 
on October 20, 2021. 
 
You asked the Plan to pay an additional amount for the dental service. You say that you would like this to be 
paid. The Plan denied your request. The Plan says the claim was processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and crown is listed as covered service, 
there is a coinsurance that applies. The Evidence of Coverage shows that you pay 70% for crowns that you 
receive from an in network provider. This is a contractual obligation you agreed to when you enrolled in the 
Plans dental coverage. Therefore, we decided that the Plan does not have to pay an additional amount for the 
porcelain crown (D2740) provided on October 20, 2021.
Appeal type: Surgery
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 the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the thermal radiofrequency destruction of cervical, 
thoracic, or lumbar paravertebral facet joint (median branch) nerves are considered medically reasonable and 
necessary when specific criteria are met.  
 
 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 the services are not medically necessary. Our physician reviewer found there is no documentation 
submitted for diagnostic medial branch block (MBBs) on the left. Therefore, at this point, the request is 
deemed not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a catheter placement procedure performed 
on October 14, 2021. 
 
You asked the Plan to waive the coinsurance for the catheter placement. You say that you were informed that 
you would not be billed for the procedure. 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 10% 
coinsurance for surgery or other services provided at an outpatient hospital or ambulatory surgical center.  
 
You have been asked to pay $328.57, which is 10% of the allowed amount for the catheter placement ($3,285.69 allowed amount x 10% coinsurance = $328.57). The catheter placement 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 catheter placement procedure performed on 
October 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (99308) and debridement of 
the muscle and or fascia (11043) provided on September 20, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care and debridement of the muscle and or fascia. 
You say that the claim was denied due to requested medical records not being received and you would like to 
appeal with supporting records. The Plan denied your request. The Plan says this provider is a non-network 
provider who does not work with the Plan and the member was referred by his non-participating nursing 
facility. The Plan also says that the member's primary care physician (PCP) did not refer for services and no 
medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been 
documented. The Plan also says that alternate network providers were found. 
 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 subsequent nursing facility care (99308) and 
debridement of the muscle and or fascia (11043) provided on September 20, 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 the medical services rendered on June 13, 2021. 
 
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 procedure code 99053 is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is 
always bundled into payment for other services not specified. 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Billed procedure code 99053 (service[s] provided between 10:00 PM 
and 8:00 AM at 24-hour facility, in addition to basic service) has a status indicator of B and no separate 
Medicare payment. Therefore, we decided that the Plan does not have to pay for the medical services rendered 
on June 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on September 14, 2021. 
 
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 procedure code 43752 is not supported. 
 
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 43752 is naso- or oro-gastric tube placement, requiring 
physician's skill and fluoroscopic guidance (includes fluoroscopy, image documentation and report). 
 
We find that CPT code 43752 is not supported in the medical record. Specifically, there is no imaging 
documentation to support the billed code. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the 
surgical services rendered on September 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic mammography provided on 
October 7, 2021. 
 
You asked the Plan to waive the copayment for diagnostic mammography. You say that the copayment should 
be waived because you were misinformed. The Plan denied your request. The Plan says the copayment amount 
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 a $100 
copayment for X-rays performed in an outpatient hospital facility.  
 
You have been asked to pay a $100 copayment for diagnostic mammography. Diagnostic mammography 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 diagnostic mammography provided on October 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on January 26, 2021.  
You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says there is not an established relationship between the 
enrollee and ordering physician. 
 
The Plan must follow Medicare rules. Medicare rules say that unless provided otherwise, other services 
included on the Medicare telehealth services list must be furnished using, at a minimum, audio and video 
equipment permitting two-way, real-time interactive communication between the patient and distant site 
physician or practitioner. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the office visit have not been met. Specifically, the documentation does not clearly indicate that the 
service was furnished using audio and video equipment permitting two-way, real-time interactive 
communication between the patient and distant site physician or practitioner. CPT code 99202 is not included 
on the list of codes which are appropriate for audio-only telehealth services. The documentation does not 
clearly show if this service was furnished using audio-only or audio-video communication. Therefore, we 
decided that the Plan does not have to pay for the office visit (99202) provided on January 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cystourethroscopy provided to the enrollee on September 16, 
2019. 
 
You asked the Plan to pay for the services. You say that you have not received payment. The Plan denied your 
request. The Plan says payment for this post-operative visit was included in the payment for the surgical 
procedure. 
 
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 52310 is "Cystourethroscopy, with removal of foreign 
body, calculus, or ureteral stent from urethra or bladder (separate procedure); simple." 
 
We find that CPT code 52310 is not supported in the medical record. Specifically, this service was billed 
during the global period of the surgery. It cannot be paid separately. 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 cystourethroscopy provided to the enrollee on September 16, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 13, 2021. 
 
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 procedure codes 87798, 87481, 87640, and 87653 are not separately payable. 
 
  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 87801, 87798, 87481, 87640, and 87653. Codes 87798, 
87481, 87640, and 87653 are column II codes with a modifier indicator of 1 when billed with column I code 
87801. The column II codes were not billed with an appropriate modifier to allow for separate payment. 
Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99204) radiologic examination, 
spine, lumbosacral (72100) radiologic examination, spine, cervical, two or three views (72040) radiologic 
examination, spine, thoracic (72070) provided July 16, 2021. 
 
You asked the Plan to pay for the chiropractic services. You say that this enrollee's deductible was already met. 
There benefits state that office visits are covered at 100% and x-rays are 15% coinsurance, neither of which 
were paid for. The Plan denied your request. The Plan says these services are not covered when rendered by a 
chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the outpatient office visit (99204) radiologic examination, spine, lumbosacral 
(72100) radiologic examination, spine, cervical, two or three views (72040) radiologic examination, spine, 
thoracic (72070) provided July 16, 2021.