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

 
We decided that the Plan does not have to pre-approve a CT Coronary Calcification Electron Beam Computed 
Tomography (EBCT). 
 
You asked the Plan to pre-approve a CT Coronary Calcification (EBCT). The Plan denied your request. The 
Plan says the CT Coronary Calcification (EBCT) does not meet the Medicare LCD and the Plan's Medical 
Policy 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 a CT Coronary Calcification (EBCT). 
Our reviewer says that a CT Coronary Calcification (EBCT) is not medically necessary. Our physician 
reviewer found that in this case, the record indicates that the enrollee has exertional dyspnea most likely from 
deconditioning. The record does not provide the results of any cardiac evaluation. The record indicates that the 
requested test is being done for screening purposes. The elements of the coverage criteria are not satisfied.  
 
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 CT Coronary Calcification (EBCT) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a CT Coronary Calcification (EBCT).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve echocardiography (93306) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve echocardiography. You say that this service is necessary. The Plan denied 
your request. The Plan says out-of-network care is covered only in certain limited circumstances. The requested 
care is not urgent or emergent and can be performed by an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 
echocardiography (93306) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection provided on January 20, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the injection. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advance. 
 
 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 injection provided on January 20, 2022 by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the automatic external defibrillator rentals (K0606) rendered 
by the out-of-network (OON) provider from August 3, 2021, through October 3, 2021. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says the items were rendered by an out of network 
provider, without prior authorization. 
 
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 at issue in this appeal. The Plan did not pre-approve the items at issue.  We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan 
does not have to pay for the automatic external defibrillator rentals (K0606) rendered by the out-of-network 
(OON) provider from August 3, 2021, through October 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for a Retacht injection provided on January 19, 
2022. 
 
You asked the Plan to reduce the cost share for an injection. You say that you are now paying a $50 deductible 
and $69.28 for this shot. 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 20% 
coinsurance for in-network Part B drugs.  
 
The record shows this claim was approved, and you have a cost sharing amount. The Plan confirmed that the 
claim from December 2021 you mentioned in your appeal was billed with services other that the injection, resulting in an additional copayment. You have been asked to pay $69.28, which is 20% coinsurance of the 
allowed amount for an injection received on January 19, 2022 ($346.40 allowed amount x 20% coinsurance = 
$69.28). 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 reduce the cost share for a Retacht injection provided on January 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 22, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says this is not a 
covered screening test.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on October 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an X-Ray examination provided on August 6, 2021. 
 
You asked the Plan to pay for X-Ray. You say that the enrollee revoked hospice on August 5, 2021 so the Plan 
should pay this claim. The Plan denied your request. The Plan says the denial of payment for this claim is 
correct, because the enrollee revoked hospice on August 5, 2021 so the Plan is not responsible for payment of 
this claim. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated.  
The enrollee ended Medicare Hospice benefits on August 5, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for an X-Ray 
examination provided on August 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the insertion of a non-tunneled central venous catheter 
provided on June 2, 2021, billed with code 36556. 
 You asked the Plan to pay for the catheter insertion as billed. You say that this was medically necessary and 
should be paid as billed. The Plan denied your request. The Plan says a proper NCCI edit was not used to allow 
for payment of both 93503 and 36556 on this date of service. 
 
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 36556 
is a column II code to column I code 93503. 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 insertion of a non-tunneled central venous catheter provided 
on June 2, 2021, billed with code 36556.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have waive your $1472 copayment for a Skilled Nursing Facility stay from 
October 1, 2021, to October 28, 2021. 
 
You asked the Plan waive your $1472 copayment for your Skilled Nursing Facility stay. You say that you were 
told you would not be responsible for a copayment if you went to a Skilled Nursing Facility due to a COVID-
related illness. The Plan denied your request. The Plan says you must pay a $184 copayment per day for days 
21 to 100 of your Skilled Nursing Facility stay. 
 
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 $184 
copayment per day for days 21 to 100 of a Skilled Nursing Facility stay. for Skilled Nursing Facility (SNF) 
Care.   
You have been asked to pay a $1472 copayment for your Skilled Nursing Facility stay: $0 days for 0 to 21, 
$184/day for days 21 to 100 ($184 x 8=$1472). Skilled Nursing Facility stays fall within the Skilled Nursing 
Facility (SNF) 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 waive your $1472 copayment for a Skilled 
Nursing Facility stay from October 1, 2021, to October 28, 2021.  
 
Your complaint about being given incorrect information regarding the Plans COVID-19 related cost sharing 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an inpatient hospital care provided on 
November 17, 2021. 
 
You asked the Plan to waive the deductible for the inpatient hospital care. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible which applies to Inpatient hospital care.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category Inpatient 
hospital care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible which applies to Inpatient hospital care. This cost sharing is a contractual obligation that had not 
been met at the time the inpatient hospital care was received on November 17, 2021. Therefore, we decided 
that the Plan does not have to waive the deductible for an inpatient hospital care provided on November 17, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services provided on November 16, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the surgery services. You say that it was the facilities responsibility to obtain 
prior authorization and it was medically necessary to treat the enrollee. The Plan denied your request. The Plan 
says the rendering provider is an OON provider and there was no referral from an in-network provider or an 
approved authorization. Also, the service rendered was not urgent or emergent. 
 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 surgery services provided on November 16, 
2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on January 14, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the OON drug testing. You say that the testing was medically necessary and 
should be reimbursed. The Plan denied your request. The Plan says this was ordered by an OON provider 
without authorization. 
 
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 drug testing provided on January 14, 2022 by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
November 15, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you get this shot every six 
months and have never been charged. You also say you never see a doctor when you go in for the shots. 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 $5 
copayment for other health care professional services in a specialist office.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$5 copayment for a specialist office visit. A specialist office visit falls within the Physician/Practitioner Services, Including Doctors Office Visits 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 a specialist office visit provided on November 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cervical and lumbar x-rays provided on 
February 11, 2022, and laboratory services provided on February 14, 2022. 
 
You asked the Plan to waive the copayment for x-rays and laboratory services. You say that you cannot afford 
these payments. You also say you did not know that you would have had lower copayments or no copayment at 
all if you went to a different facility. 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 $150 
copayment for in-network x-rays at an outpatient hospital facility. The Plan contract also says that enrollees 
must pay a $40 copayment for in-network laboratory services at an outpatient hospital facility.   
 
You have been asked to pay the allowed amount of $108.79, which is less than the $150 copayment for x-rays. 
You have also been asked to pay a total of $37.89, which is less than the $40 copayment for laboratory services 
($3 + $10.56 + $13.39 +7.77 +$3.17 = $37.89). The x-rays and laboratory services fall within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for cervical and lumbar x-rays provided on February 11, 2022, and laboratory services provided 
on February 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Chiropractic Care provided on January 17, 2022 to February 
9, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Chiropractic Care. You say that you would like to appeal the denial of the claim. 
The Plan denied your request. The Plan says the member's plan excludes coverage for this OON service. 
 
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 Chiropractic Care provided on January 17, 2022 to 
February 9, 2022 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an arthrocentesis with ultrasound guidance 
provided on November 23, 2021. 
 
You asked the Plan to reduce the copayment for an arthrocentesis. You say that you do not understand why the 
insurance did not pay anything. You also say you had the same procedure in March 2022 and only had a $50 
copayment. 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 
copayment for in-network outpatient surgery at an outpatient hospital facility.  
 
 An arthrocentesis is a covered surgical procedure that has a cost sharing amount. If the allowed amount is less 
than the cost share amount found in the EOC, you are responsible for the full allowed amount. You have been 
asked to pay the allowed amount of $261.22, which is less than the $350 copayment for an arthrocentesis. An 
arthrocentesis 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 reduce the copayment for 
an arthrocentesis with ultrasound guidance provided on November 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64491, 64490, 64492). 
 
You asked the Plan to pre-approve the facet joint injections. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says coverage rules have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that this service is covered when there is no non-facet 
pathology per clinical assessment or radiology studies that could explain the source of the patient's pain. 
 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 facet joint injections. Our reviewer 
says that the injections are not medically necessary. Our physician reviewer found the imaging shows that the 
enrollee has herniated discs which impinge on the spinal cord at the levels being treated, which is a clinical 
reason for pain in this area. The MRI also shows that the member has normal facet joints with no evidence of 
arthropathy. 
 
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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections (64491, 64490, 64492).