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

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
January 9, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the enrollee should 
not be responsible due to the substandard care received at the hospital. The Plan denied your request. The Plan 
says the enrollee was 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $150 copayment for each one-way ground ambulance trip.  
 
The enrollee has been asked to pay a $150 copayment for the ambulance transportation. The ambulance 
transportation falls within the Ambulance Services benefit category. This means that the enrollee 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 upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for ambulance transportation provided on January 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit on January 14, 2022. 
 
You asked the Plan to waive the deductible for an office visit. You say that you do not know why the plan paid 
nothing and why you are paying more than the co-pay. The Plan denied your request. The Plan says the cost 
share 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 a $250 
deductible before the plan will pay their share for your covered medical costs. Prior to receiving services on 
January 14, 2022, your deductible had not been met. 
 
You have been asked to pay a $250 deductible for an office visit. An 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 deductible for an office visit on January 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on January 10, 2022. 
 
You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says the services were billed twice. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 We looked at the file and the rules. We find that the services at issue were billed twice by the same provider for 
the same date of service. The records provided do not show that separate services described by the same codes 
were provided. Based on this information, we decided that Medicare rules for coverage not been met. 
Therefore, we decided that the Plan does not have to further pay for the emergency room services provided on 
January 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for debridement provided January 31, 2022. 
 
You asked the Plan to waive the copayment for debridement. You say that the referring doctor said the facility 
was a wound center.  You say that this should be a $35 copayment for a specialist visit and not a hospital visit. 
The Plan denied your request. The Plan says you have been charged the correct copayment 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 $335 
copayment for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, 
including but not limited to hospital or other facility charges and physician or surgical charges.  
 You have been asked to pay $326.75 which is less than the $335 copayment. Debridement falls within the 
Outpatient surgery and Other Medical services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers benefit category. The outpatient clinic visit provided on January 24, 2022 was fully paid and 
you were not charged for that service. 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 debridement 
provided January 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for shaving a skin lesion of the trunk/arm/leg, the shaving a skin 
lesion, the destruction premalignant lesion, and destruction premalignant lesions 1st, and the destruction of a 
premalignant lesion 2-14 provided on September 8, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for shaving a skin lesion of the trunk/arm/leg, the shaving a skin lesion, the 
destruction premalignant lesion, and destruction premalignant lesions 1st, and the destruction of a premalignant 
lesion 2-14. You say that you were never told that you needed to see a specific doctor or needed to be in a 
specific area, and you were never given a list or guide. You also say that cancer is an emergency. The Plan 
denied your request. The Plan says the medical care you require can be provided by a network provider, and 
that the information about seeing doctors in the network came to you in the letter that was sent to you on 
January 6, 2020. The Plan also says that the services that you received were not emergent/urgent and 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 shaving a skin lesion of the trunk/arm/leg, the 
shaving a skin lesion, the destruction premalignant lesion, and destruction premalignant lesions 1st, and the 
destruction of a premalignant lesion 2-14 provided on September 8, 2021, 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 supply allowance used with a therapeutic CGM device 
(K0553) provided November 4, 2021. 
 
You asked the Plan to pay for the supply allowance used with a therapeutic CGM device. You say that kindly 
find all the attached records and reprocess the claim. The Plan denied your request. The Plan says the records 
do not support the billed service. 
 The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the supply allowance used with a therapeutic 
CGM device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the review has determined that the enrollee does have 
diabetes. The enrollee is not treated with insulin with three or more daily administrations of insulin or a 
Medicare-covered continuous subcutaneous insulin infusion pump. The enrollees insulin regimen does not 
require frequent adjustment by the beneficiary on the basis of BGM or CGM testing results 
 
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 supply allowance used with a therapeutic CGM device have not been met. 
Therefore, we decided that the Plan does not have to pay for the supply allowance used with a therapeutic 
CGM device (K0553) provided November 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) you received on June 
21, 2021. 
 
You asked the Plan to pay for the DME. The Plan denied your request. The Plan says this provider does not 
participate in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the durable medical equipment (DME) 
you received on June 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed. 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that you disagree with the plan's 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested item. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that the documentation does not support that the requested semi-electric hospital bed is medically 
reasonable or necessary. Our physician reviewer found the enrollee has a medical history of osteoarthritis, hip 
pain, and has undergone a recent right hip arthroplasty procedure. There is no documentation that the enrollee's 
condition requires position of the body in ways not feasible in an ordinary bed. There is no documentation that 
the enrollee requires frequent changes in body position or immediate changes in body position. There is no 
documentation that the enrollee's condition requires special attachments that cannot be fixed and used on an 
ordinary bed. Therefore, the enrollee does not meet criteria for the requested item. 
 
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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent non-chemotherapy infusion (96367) 
chemotherapy administration, intravenous infusion technique; each additional hour (96415) Therapeutic, 
prophylactic, or diagnostic injection (specify substance or drug) (96375) chemotherapy administration, 
intravenous infusion technique; up to one hour, single or initial substance/drug (96413) diphenhydramine hcl 
injection (J1200) Meloxicam Injection (J3490) rituximab injection (J9312) provided December 22, 2021. 
 
You asked the Plan to pay for the chemotherapy services. You say that the authorization for this procedure was 
granted so you do not understand why this claim was denied. The regular center was not available for your 
12/22 appointment so you were directed by them to have your infusion at the other center. The Plan denied 
your request. The Plan says the service performed, the servicing provider, or the number of visits billed do not 
match what was approved on the authorization. 
 
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 find that the provider billed with the wrong tax ID and did not bill with the correct CMS 1500 
form. The provider with a UB form. The provider must send a corrected claim on the correct form. Based on 
this information, we decided that Medicare rules for coverage of the chemotherapy services have not been met. 
Therefore, we decided that the Plan does not have to pay for subsequent non-chemotherapy infusion (96367) 
chemotherapy administration, intravenous infusion technique; each additional hour (96415) Therapeutic, 
prophylactic, or diagnostic injection (specify substance or drug) (96375) chemotherapy administration, 
intravenous infusion technique; up to one hour, single or initial substance/drug (96413) diphenhydramine hcl 
injection (J1200) Meloxicam Injection (J3490) rituximab injection (J9312) provided December 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for acupuncture for chronic low back pain on 
March 02, 2022. 
 
You asked the Plan to waive the copayment for acupuncture. You say that you were told to appeal this decision 
because the doctor does not have a NPI and was told originally that that was the reason for denying the claim. 
The Plan denied your request. The Plan says the cost-sharing amount 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 a $20 
copayment for each Medicare-covered acupuncture visit.  
 
You have been asked to pay a $20 copayment for each acupuncture visit. Acupuncture visits fall within the in-
network Medicare-covered visit. You have a $20 copayment for each Medicare-covered service, and a $20 
copayment for each non-Medicare covered acupuncture visit, up to 6 visits each year. The allowed amount on 
this claim is $20. 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 acupuncture for chronic low 
back pain on March 02, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lucentis (J2778) and injection (67028). 
 
You asked the Plan to pre-approve Lucentis. You say that the enrollee has been on this medication since 2019. 
You say that you have had this treatment in the past. You also say that the enrollee has never tried any other 
medication besides this. The Plan denied your request. The Plan says the enrollee has not tried and failed the 
preferred drug, Avastin. 
 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 Lucentis. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the preferred drug, Avastin. The reviewer found that the 
documentation does not support that Avastin would likely be less effective, and/or would likely have adverse 
effects for the enrollee in this case. Therefore, the reviewer found that the step therapy criteria have not been 
met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lucentis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Lucentis (J2778) and injection (67028).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cytopathology, in situ hybridization (eg, fish), urinary tract 
specimen with morphometric analysis (88121) provided November 10, 2021. 
 You asked the Plan to pay for the laboratory services. You say that the diagnosis code does not substantiate the 
service. The Plan denied your request. The Plan says code 88121 is not a Medicare benefit for the diagnosis 
listed (R31.21, asymptomatic microscopic hematuria) and is done for screening purposes. Urine cytology is not 
considered a bladder tumor marker. 
 
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 test at issue in this appeal, the laboratory services, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for cytopathology, in situ hybridization (eg, fish), urinary tract specimen with morphometric analysis (88121) 
provided November 10, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided April 1, 2021, to 
April 2, 2021. 
 
You asked the Plan to pay for the acute inpatient level of care. You say that additional payment should be 
made. The Plan denied your request. The Plan says the claim processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that the plan that covered the enrollee at the 
beginning of an inpatient stay is responsible for the entire stay. If there is a change in coverage during the stay, 
the new Plan is not responsible for inpatient hospital care until after the date of discharge.  
 
A different health plan was not the Plan of record at the time of the inpatient stay at issue in this appeal began. 
This means that the new plan is not responsible for coverage of inpatient hospital services until after this stay ended. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided 
April 1, 2021, to April 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for cataract surgery and phenylephrine 
irrigation solution provided on January 11, 2022. 
 
You asked the Plan to waive the cost share for cataract surgery and phenylephrine irrigation solution. You say 
that you do not have the money to pay this bill. 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 Plan contract also says that enrollees must pay a $225 copayment 
for in-network outpatient surgery at an ambulatory surgical center. 
 
You have been asked to pay $78.82, which is 20% coinsurance of the allowed amount for phenylephrine 
irrigation solution ($394.12 allowed amount x 20% coinsurance = $78.82). Phenylephrine irrigation solution 
falls within the Medicare Part B Prescription Drugs benefit category.  
 
You have also been asked to pay a $225 copayment for cataract surgery. Cataract surgery falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers benefit category. You have been asked to pay a total of $303.82 ($78.82 coinsurance + $225 
copayment = $303.82). 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 cost share for cataract surgery and 
phenylephrine irrigation solution provided on January 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical techniques requiring use of robotic surgical 
system identified with code S2900 provided on October 28, 2021. 
 
You asked the Plan to pay for the surgical techniques requiring use of robotic surgical system. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed 
are not payable. 
 
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 S2900 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code S2900 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of the surgical techniques requiring use of robotic surgical system have not been met. Therefore, we 
decided that the Plan does not have to pay for the surgical techniques requiring use of robotic surgical system 
identified with code S2900 provided on October 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the introduction of needle or intracatheter services coded 
36000 provided on September 6, 2021. 
 
You asked the Plan to pay for the introduction of needle or intracatheter services. You say that you would like 
the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not 
separately payable. 
 
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 36000 is introduction of needle or intracatheter, vein. 
 
 
 We find that CPT code 36000 is not supported in the medical record. Specifically, this code has a status code of 
"B". This means payment for this service is always bundled into payment for other services not specified. No 
separate payment can be made. Based on this information, we decided that Medicare rules for coverage of the 
introduction of needle or intracatheter services have not been met. Therefore, we decided that the Plan does not 
have to pay for the introduction of needle or intracatheter services coded 36000 provided on September 6, 
2021.