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

 
We decided that the Plan does not have to waive the copayment for outpatient facility services provided on 
February 9, 2022. 
 
You asked the Plan to waive the copayment for the outpatient facility services. You say that you had no choice 
of what location the doctor would be at and you were not advised of there being a copayment. The Plan denied 
your request. The Plan says the copayment was 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 $390 
copayment per visit.  
 
 
  You have been asked to pay $390 for the outpatient facility services. The outpatient facility services fall 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 copayment for outpatient facility services 
provided on February 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cataract surgery provided on May 4, 2021, 
to October 19, 2021. 
 
You asked the Plan to waive the copayment for cataract surgery. You say that the surgery was done incorrectly 
so it should be covered. The Plan denied your request. The Plan says the copayment 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 $380 
copayment for Medicare-covered outpatient surgery in an ambulatory surgical center. 
 
 
 
 
 You have been asked to pay $ 1,140 ($380 x 3 visits) copayment for cataract surgery. Cataract surgery 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 copayment for cataract surgery provided 
on May 4, 2021, to October 19, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 29, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says in accordance with Medicare guidelines, 
this claim needs to be billed to Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the laboratory services provided on December 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cranial prosthesis (wig). 
 
You asked the Plan to pre-approve wig. You say that you are appealing this denial. The Plan denied your 
request. The Plan says a wig is not covered by Medicare. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a cranial 
prosthesis (wig).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation with a specialist to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the consultation with a specialist. You say that the in-network providers 
could not help you and you would like to see the OON provider. The Plan denied your request. The Plan says 
there are multiple in-network providers that are available with the specialties that the enrollee needs. 
 
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 
a consultation with a specialist to be provided 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 rituximab injection provided on March 24, 
2022. 
 
You asked the Plan to waive the coinsurance for rituximab injection. You say that you met your out-of-pocket 
and shouldn't have to pay for this. 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 chemotherapy, prescription drugs and immunizations. 
 
 
 
 
 You have been asked to pay $70 which is less than the standard 20% coinsurance because you met your out-of-
pocket during this claim for rituximab injection. Rituximab injections fall 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 rituximab injection 
provided on March 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lightweight wheelchair (K0003) provided on June 27 to 
July 26, 2021. 
 
You asked the Plan to pay for a lightweight wheelchair. You say that you have provided medical records to 
support the item billed. The Plan denied your request. The Plan says rules for payment have not been met 
because the available record does not support the item billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code K0003 is "Lightweight wheelchair." 
 
We find that CPT code K0003 is not supported in the medical record. Specifically, the available medical 
documentation indicates that the item prescribed and ordered was a standard wheelchair rather than a 
lightweight wheelchair. Based on this information, we decided that Medicare rules for coverage of a 
lightweight wheelchair have not been met. Therefore, we decided that the Plan does not have to pay for a 
lightweight wheelchair (K0003) provided on June 27 to July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (99100) provided November 2, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the code billed is not eligible for separate payment. 
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (99100) provided November 2, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-periapical first radiographic image (D0220) and 
the resin-based composite-four or more surfaces, posterior for tooth number 14 (D2394) rendered by the out-
of-network (OON) provider on March 1, 2022 and March 8, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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. The Plan contract states that 
services are only covered when rendered by a participating provider. 
 
 We looked at this case file and the Plans rules. Based on this information, we decided that the Plan's rules for 
coverage of these services have not been met. Specifically, the services in this case were rendered by an out of 
network provider. The Plan contract states that services are only covered when rendered by a participating 
provider. Therefore, we decided that the Plan does not have to pay for the intraoral-periapical first radiographic 
image (D0220) and the resin-based composite-four or more surfaces, posterior for tooth number 14 (D2394) 
rendered by the out-of-network (OON) provider on March 1, 2022 and March 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound care services provided on February 
25, 2022. 
 
You asked the Plan to waive the copayment for the wound care. You say that the enrollee was unaware of the 
copayment at the time of service. The Plan denied your request. The Plan says the enrollee has 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $225 copayment per visit for surgery or procedures at a hospital facility.  
 
The enrollee has been asked to pay a $225 copayment for the wound care. The wound care falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers 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 wound care services 
provided on February 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower transfer bench. 
 
You asked the Plan to pre-approve a shower bench. You say that this is medically necessary as without it you 
are not able to easily bathe. The Plan denied your request. The Plan says this is not a covered item under 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower transfer bench.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options and accessories. 
 You asked the Plan to pre-approve a group 3 power wheelchair with multiple power options. You say that the 
specific power wheelchair and associated accessories are medically necessary. The Plan denied your request. 
The Plan says the criteria for coverage for the requested wheelchair have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair with multiple power 
options is subject to the criteria listed 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 pre-approve a group 3 power wheelchair with 
multiple power options. Our reviewer says that the requested power wheelchair with multiple power options is 
not medically reasonable and necessary. Our physician reviewer found based on the medical records provided 
there is no documentation that the enrollee meets all of the criteria for coverage in Local Coverage 
Determination (LCD) L33789: Power Mobility Devices for the group 3 power wheelchair with multiple power 
options with power tilt and recline. Provided records do not document that the enrollee is high risk for skin 
breakdown or has increased lower extremity muscle tone or spasticity or requires intermittent bladder 
catheterization to meet criteria for the multiple power options with power tilt and recline. As the criteria for a 
power tilt option have not been met, the group 3 power wheelchair with multiple power options is not 
medically reasonable and 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 a group 3 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple 
power options and accessories.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex. 
 
You asked the Plan to pre-approve Vertiflex. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you have bilateral lower back pain and mid back pain. The Vertiflex device is experimental. 
More research is needed to show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vertiflex.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
February 20, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you were not given 
the option to drive the enrollee yourself. The Plan denied your request. The Plan says the enrollee has 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $275 copayment for each one-way ambulance transport.  
 
The enrollee has been asked to pay $248.65, which is less than the $275 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 February 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve dialysis services. You say that you want to continue to go to the out-of-
network provider because they are close to your home. The Plan denied your request. The Plan says as of June 
1, 2022, the dialysis center you had been receiving care from will be a non-contract provider and you were 
notified in writing of a new dialysis center that is contracted with the Plan, within 16 minutes of your home.  
 
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 
dialysis services to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a specialist office visit provided on 
February 23, 2022. 
 
You asked the Plan to reduce the copayment for the office visit. You say that you only saw a nurse practitioner 
and should only owe a $15 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 $30 
copayment for each specialist visit.  
 
You have been asked to pay a $30 copayment for the office visit. The office visit falls within the 
Physician/Practitioner Services, Including Doctor's 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 reduce the copayment for a specialist office visit provided on February 23, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) 
(G0299). 
 
You asked the Plan to pre-approve direct skilled nursing services of a RN. The Plan denied your request. The 
Plan says the wound is healed, and there is no need for continued home health wound services. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 direct skilled nursing services of a RN. 
Our reviewer says that the requested, home health skilled nursing services are not medically necessary or 
reasonable. Our physician reviewer found the enrollee does not have documented skilled nursing needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of direct skilled nursing services of a RN have not been met. Therefore, we 
decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) 
(G0299).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy evaluation (97163) provided on January 
14, 2021. 
 
You asked the Plan to pay for the physical therapy evaluation. You say that these services were billed 
appropriately. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) 
Procedure to Procedure (PTP) edit exists between G0238 and 97163. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with 
this PTP code edit. This service was not billed appropriately by Medicare coding regulations. 
 
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 97163 
is a column II code to column I code G0238. 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 physical therapy evaluation (97163) provided on January 14, 
2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on June 15, 2021. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary and 
provided in good faith. The Plan denied your request. The Plan says it is not responsible for paying this claim 
because the patient was enrolled in hospice on the date of service in question. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided on June 15, 2021.