Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for ankle foot orthosis (L4397) provided on 
August 5, 2021. 
 
You asked the Plan to waive the deductible for the ankle foot orthosis. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the deductible 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 $1000 deductible which applies to Durable medical equipment 
(DME) and related supplies.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category Durable 
medical equipment (DME) and related supplies. The Plan has followed Medicare rules by clearly disclosing in 
the contract that there is a $1000 deductible which applies to Durable medical equipment (DME) and related 
supplies. This cost sharing is a contractual obligation that had not been met at the time the ankle foot orthosis 
was received on August 5, 2021. Therefore, we decided that the Plan does not have to waive the deductible for 
ankle foot orthosis (L4397) provided on August 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bifocal lens you purchased on December 6, 2021. 
 You asked the Plan to pay for the bifocal lens. You say that you believe you are eligible for coverage. The Plan 
denied your request. The Plan says you were not eligible for coverage of a bifocal lens on this date of service. 
You already received coverage for a bifocal lens on February 2, 2021. 
 
Medicare generally does not cover routine vision services and eye wear. However, the Plan offers a routine 
vision and eye wear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers lenses once per calendar year.  You already received coverage for lenses on February 
2, 2021, so you were not eligible for more lenses when you purchased a bifocal lens on December 6, 2021. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the bifocal lens have not been met. Therefore, we decided that the Plan does not have to pay for the 
bifocal lens you purchased on December 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214-25 billed for date of service October 
5, 2021. 
 
You asked the Plan to pay for procedure code 99214-25. You say that you have provided medical records to 
support payment for this code. The Plan denied your request. The Plan says the medical records do not support 
the -25 modifier that was appended to code 99214, so this evaluation and management code is not separately 
payment from the wound care procedure code (11042) billed on that same date. 
 
The Plan must follow Medicare rules. Medicare rules say that generally, evaluation and management services 
performed on the same day as a procedure are part of the global payment for the procedure and no separate 
payment is made.  However, if the evaluation and management service is significant and separately identifiable 
from the primary procedure, there can be separate payment if the provider appropriately appends the -25 modifier. 
 
In this case you did append the -25 modifier for the 99214 evaluation and management code.  However, the 
medical records do not indicate that a significant or separately identifiable service from the wound care 
procedure occurred.  The medical records from this visit only discuss the care of the patient's wound.  No other 
conditions, diagnoses, or procedures are noted in the medical record that would indicate that the evaluation and 
management code was significant or separately identifiable from the wound care procedure itself. Based on this 
information, we decided that Medicare rules for coverage of procedure code 99214-25 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99214-25 billed for date of service 
October 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for a magnetic resonance 
imaging (MRI) of the abdomen and a gadobutrol (contrast agent) injection provided on November 17, 2021. 
 
You asked the Plan to waive the copayment and coinsurance for the MRI and contrast agent. You say that the 
procedure should be fully covered. The Plan denied your request. The Plan says the correct copayment and 
coinsurance were 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 $105 copayment for radiological diagnostic services, including MRI's. 
 
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for medical supplies, such 
as chemical agents used in certain diagnostic procedures. 
 
You have been asked to pay a $105 copayment for the MRI. You have also been asked to pay $5.60for the 
contrast agent, which is 20% of the allowed amount ($28.00 allowed amount x 20% coinsurance = $5.60). The 
total for the procedure is $110.60. The MRI and contrast agent 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 and 
coinsurance for a magnetic resonance imaging (MRI) of the abdomen and a gadobutrol (contrast agent) 
injection provided on November 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on October 
28, 2021. 
 
You asked the Plan to pay for the special anesthesia service (99100). You say that anesthesia was needed for 
this procedure and the claim should be reprocessed. The Plan denied your request. The Plan says procedure 
code 01936 has been overturned and procedure code 99100 remains denied as bundled services are not eligible 
for separate reimbursement.  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 special anesthesia service (99100) have not been met. Therefore, we decided that the Plan does not have 
to pay for the special anesthesia service (99100) provided on October 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided from October 7, 2021, to 
November 4, 2021. 
 
You asked the Plan to pay for the acupuncture services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements.  
 We looked at the file and Medicare rules. The records do not show that the acupuncture services were furnished 
under the supervision of a physician, PA, NP, or CNS. Based on this information, we decided that Medicare 
rules for coverage of the acupuncture services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acupuncture services provided from October 7, 2021, to November 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of Barostimulator for heart failure. 
 
You asked the Plan to pre-approve the surgical services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the request for implantation of a Barostimulator for heart failure (a 
device put under the enrollee's skin used to manage their heart failure) is considered experimental and 
investigational; therefore, this service is not covered as it is not proven to be safe and or efficacious (successful 
in producing a desired result). 
 
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 surgical services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the remains an absence of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of Barostim Neo in patient management. As a result, at this time the 
Barostim Neo system would not be considered medically reasonable and necessary in this enrollee's clinical 
management. 
 
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 surgical services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve implantation of Barostimulator for heart failure.
Appeal type: SNF
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment for the discharge day. We decided that the Plan does not 
have to waive the copayment for the remaining days.  
 
You asked the Plan to waive the copayment for SNF. You say that the enrollee should not have to pay this bill 
because the quality-of-care was not acceptable. The Plan says that copayment is correct. 
 
 We decided that the Plan has to waive the copayment for the discharge day.  
 
The copayment for inpatient services does not apply to the discharge day. There was no evidence that this SNF 
stay continued past December 31, 2021, to apply a copayment to this day. Therefore, we decided the Plan has 
to waive the copayment for the discharge day. 
 
We also decided that the Plan does not have to waive the copayment for the remaining days. 
 
Date of Service SNF Days Number of Days Copayment Member Liability 
December 8, 2021- 
December 27, 2021 
1-20 20 $0/day $0 
December 28,2021- 
December 31, 2021 
21-23 3 $80/day $240 
TOTAL:    $240 
 
The Plan contract clearly says that enrollees pay an $80 copayment for days 21-100. The copayment does not 
apply to the discharge day. Therefore, we decided that the Plan does not have to reduce the copayment from 
$320 to $240. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve the readmission for inpatient hospital care. 
 
You asked the Plan to pre-approve the readmission for inpatient hospital care. You say that the stay is 
medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary. 
 
The Plan follows Medicare Rules. Medicare rules say that inpatient readmission is covered when medically 
necessary, and if the readmission did not result from a premature discharge from the same hospital. 
 
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 readmission for inpatient hospital 
care. Our physician reviewer found the review has determined that the admission is medically necessary. The 
readmission did not result from a premature discharge from the same hospital.  
 
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 readmission for inpatient hospital care have been met. Therefore, we 
decided that the Plan has to pre-approve the readmission for inpatient hospital care.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional Modivcare mileage. 
 
You asked the Plan to pre-approve additional Modivcare mileage.. You say that you are requesting additional 
mileage. The Plan denied your request. The Plan says the routes requested will have exceeded your benefit 
mileage limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. We looked at your request, the records in the case file, and the rules. The shortest route is 101 miles with 
highways, tolls and ferries, and 108 miles avoiding highways, tolls, and ferries. These routes will have 
exceeded your benefit mileage limit. The health plan contract says each one-way trip must not exceed fifty (50) miles of driving distance. A trip is one-way transportation; a round trip is two (2) trips. Therefore, we decided 
that the Plan does not have to pre-approve additional Modivcare mileage.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for a denosumab injection 
provided on December 8, 2021. 
 
You asked the Plan to waive the copayment and coinsurance for the injection. You say that you do not know 
what the bill is for. The Plan denied your request. The Plan says the correct copayment and 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 $395 
copayment for surgery or other services provided at an outpatient hospital. Your contract with the Plan also clearly says that you must pay a 20% coinsurance for each Part B drug. 
 
You have been asked to pay $74.67 for the injection procedure, which is less than the $395 copayment. The 
injection procedure falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient 
Facilities and Ambulatory Surgical Centers benefit category. You have also been asked to pay $185.90 for the 
denosumab drug, which is 20% of the allowed amount ($929.52 allowed amount x 20% coinsurance = 
$185.90). The denosumab drug falls within the Medicare Part B Prescription Drugs benefit category. The total 
for the visit is $260.57. 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 and coinsurance for a denosumab 
injection provided on December 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extra-wide electric scooter. 
 
You asked the Plan to pre-approve an extra-wide electric scooter. You say that that the wheelchair provided to 
you in January 2018 does not work properly as your condition has worsened and the device is too small for you 
due to your weight. The Plan denied your request. The Plan says you do not meet the Medicare guidelines for a 
power mobility device. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that you do not have a mobility deficit that impairs your participation in MRADLs or that you 
have limitations to upper extremity strength, pertinent mobility and ADL issues related to neurological deficits, 
to ambulate with a standard wheelchair, walker or cane. This means that Medicare rules for coverage of a PMD 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an extra-wide electric 
scooter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on September 30, 2021, by 
an OON provider. 
 
You asked the Plan to pay for the outpatient services. You say that you are an in-network provider, and you 
would like the claim reprocessed for payment. 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. 
 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 outpatient services provided on September 30, 
2021, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the commode chair (E0163 and S9999) provided on 
December 20, 2021. 
 
You asked the Plan to pay for the commode chair. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the provider is not enrolled in the Medicare 
program. 
 
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 commode chair (E0163 and S9999) 
provided on December 20, 2021.  
 
Your complaint about the Plan providing the incorrect information 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: Drugs
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for Part B drugs. We decided that the Plan does not have 
to reduce the coinsurance for chemotherapy and drug administration.  
 
You asked the Plan to reduce the coinsurance for chemotherapy services. You say that you have never had a 
bill this high for your infusions. The Plan says that you have been charged the correct cost sharing amount. We decided that the Plan has to waive the coinsurance for Part B drugs.  
 
The Plan says you must pay $1.04 for Part B drugs (codes J1200, J2930, J9312). According to Medicare, these 
are considered packaged codes and are not separately payable. Therefore, we decided that the Plan has to waive 
the coinsurance for Part B drugs.  
 
We also decided that the Plan does not have to reduce the coinsurance for chemotherapy and drug 
administration. 
 
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 Part B drugs and drug administration.  
 
You have been asked to pay 20% coinsurance for chemotherapy and drug administration. 
 
Date of Service Code Allowed Amount 20% Coinsurance 
October 13, 2021 96375 $344 $68.80 
October 13, 2021 96413 $770 $154 
October 13, 2021 96415 $2,277 $455.40 
 
Chemotherapy and drug administration fall within the Medicare Part B Prescription Drug 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 coinsurance for chemotherapy and drug administration. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services provided on December 6, 2021 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the lab services. You say that these services were ordered by the enrollee's 
physician. The Plan denied your request. The Plan says that the denial of payment for this service is correct, 
because this provider is out-of-network with the Plan and the ordering physician was also out-of-network with 
the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide a complete 2021 Evidence of Coverage (EOC) or any 
other evidence to support a denial of payment for this service. Therefore, we decided that the Plan has to pay 
for the lab services provided on December 6, 2021 by an out-of-network (OON) provider.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.