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

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
March 17, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you were not aware 
of the cost sharing for ambulance services. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $225 
copayment for ambulance services. 
 
You have been asked to pay a $225 copayment for the ambulance transportation. This item/service falls within 
the ambulance services benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
ambulance transportation provided on March 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Durolane injection provided on May 23, 2022. 
 
You asked the Plan to pay for Durolane. You say that the only reason you went through with the procedure is 
because you were told it was approved. You also say that you cannot afford to pay this bill. The Plan denied 
your request. The Plan says the drug in this case was not covered at the time the service was rendered. 
 
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 J7318 is hyaluronan or derivative, Durolane, for intra-
articular injection, 1 mg. 
 
We find that CPT code J7318 is not supported in the medical record. Specifically, Durolane was not supported 
as a covered code on the date of service in this case. Based on this information, we decided that Medicare rules 
for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have to pay for the 
Durolane injection provided on May 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on April 25, 
2022, to August 11, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that since these were follow ups 
to your surgery it should be covered. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for Specialist office visits. 
 
You have been asked to pay a $20 copayment for specialist office visit. This item/service falls within the 
Specialist 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. You have been asked to pay a $20 copayment per visit to see a specialist. Therefore, we 
decided that the Plan does not have to waive the copayment for specialist office visit provided on April 25, 
2022, to August 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician's services provided on July 8, 2022. 
 
You asked the Plan to pay for the physician's services. You say that this provider was recommended to you and 
your policy covers out-of-network providers and you are having a good experience, which you need to 
continue. The Plan denied your request. The Plan says the services obtained were rendered by a provider who 
does not accept Medicare assignment. The provider has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
physician's services provided on July 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prescription of optical and physical characteristics of and 
fitting of contact lenses, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia 
provided on April 26, 2022. 
 
You asked the Plan to pay for prescription of optical and physical characteristics of and fitting of contact 
lenses. The Plan denied your request. The Plan says the Plan made payment for this service rendered on  
April 15, 2021, therefore, the service has met the benefit frequency limitation and is not covered. 
 Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that the Plan made payment for this service rendered 
on April 15, 2021, therefore, the service has met the benefit frequency limitation. Therefore, we decided that 
the Plan does not have to pay for prescription of optical and physical characteristics of and fitting of contact 
lenses, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia provided on 
April 26, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for gastrointestinal services provided on July 
27, 2022. 
 
You asked the Plan to waive the copayment for gastrointestinal services. You say that you do not understand 
why you are being charged $300.00. The Plan denied your request. The Plan says this cost sharing was charged 
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 $300 
copayment for outpatient hospital services. On pages 77-78 of the Plans 2022 EOC, you get free screening 
colonoscopy every 10 years (120 months). 
 
You have been asked to pay $300 copayment for gastrointestinal services. This item/service falls within the outpatient hospital services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
gastrointestinal services provided on July 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on May 
26, 2022. 
 
You asked the Plan to pay for the oral evaluation. You say that you have had this procedure before and were 
not aware it is only covered every three years. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 14, 2021. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on May 
26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physician visit provided on June 23, 2022. 
 
You asked the Plan to pay for a physician visit. You say that you are requesting reconsideration for denied 
claim stating it should not have been the providers responsibility to acquire a referral or authorization. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a physician visit 
provided on June 23, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit provided on 
August 31, 2022, to September 02, 2022. 
 
You asked the Plan to waive the copayment for the emergency room (ER) visit. You say that the services 
should be covered based on medical necessity. The Plan denied your request. The Plan says this cost sharing 
was charged 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for the emergency room (ER) visit. This item/service falls within 
the emergency care benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room 
(ER) visit provided on August 31, 2022, to September 02, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for PET scan provided on March 15, 2022. 
 
You asked the Plan to waive the copayment for PET scan. You say that you are disputing the share cost. The 
Plan denied your request. The Plan says this cost sharing was charged 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 $300 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $300 copayment for PET scan. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for PET scan provided on March 15, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
on June 17, 2022, to July 09, 2022. 
 
You asked the Plan to waive the copayment for skilled nursing facility (SNF) care. You say that this should be 
covered. The Plan denied your request. The Plan says this cost sharing was charged 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 $80 
copayment for Skilled nursing facility (SNF) care. 
 
You have been asked to pay a $80 copayment for skilled nursing facility (SNF) care. This item/service falls 
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. You have been asked to pay a $640 ($80 x 8 days) copayment for the SNF 
stay. Therefore, we decided that the Plan does not have to waive the copayment for skilled nursing facility 
(SNF) care provided on June 17, 2022, to July 09, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for protective restoration (D2940) provided on August 17, 2022. 
 
You asked the Plan to pay for the dental service. You say that you were not advised that the service wasn't 
going to be covered by your insurance. You say you never would have agreed to any service that is not fully 
covered by your insurance, especially being on a fixed income. The Plan denied your request. The Plan says the 
requested dental procedure code is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for protective 
restoration (D2940) provided on August 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for insertion or replacement of cranial 
neurostimulator pulse generator or receiver provided on July 26, 2022. 
 
You asked the Plan to waive the cost share for insertion or replacement of cranial neurostimulator pulse 
generator or receiver. You say that you are disputing the share cost. The Plan denied your request. The Plan 
says this cost sharing was charged 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 10% 
coinsurance for outpatient hospital services. The allowed amount of this surgery total $12,191.10, resulting in a 
coinsurance amount of $1,219.11. Also, $187.62 to meet your max out of deductible which is $450. Therefore 
the total cost you are responsible is $1,406.73. 
 You have been asked to pay 10% coinsurance for insertion or replacement of cranial neurostimulator pulse 
generator or receiver. This item/service falls within the outpatient hospital services benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the cost share for insertion or replacement of cranial neurostimulator pulse 
generator or receiver provided on July 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure codes 20939, 22830, 22849, 
22852, 63042, and 63710) provided to the enrollee on July 6, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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 the denied codes is: 
 
CPT 20939: 
 
Bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (List 
separately in addition to code for primary procedure) 
 
 
 CPT 22830: 
 
Exploration of spinal fusion 
 
CPT 22849: 
 
Reinsertion of spinal fixation device 
 
CPT 22852: 
 
Removal of posterior segmental instrumentation 
 
CPT 63042: 
 
Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, 
foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar 
 
CPT 63710: 
 
Dural graft, spinal 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that all of the codes in question on this 
case are not supported in the records. The operative note does not describe any of the denied procedures. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services (procedure codes 20939, 22830, 22849, 22852, 63042, and 63710) provided to 
the enrollee on July 6, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services 
 
You asked the Plan to pre-approve the home health services. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as you 
do not meet the criteria to be approved, the care requested is considered custodial care. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve home 
health services
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation care provided on 
May 16, 2022, to June 01, 2022. 
 
You asked the Plan to waive the copayment for the inpatient rehabilitation care. You say that you paid the $100 
copayment for a previous stay, and you have not gone 60 days without a hospital stay. The Plan denied your 
request. The Plan says this cost sharing was charged 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 $100 
copayment for inpatient hospital care. 
 
You have been asked to pay a $100 copayment for the inpatient rehabilitation care. This item/service falls 
within the inpatient hospital care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
the inpatient rehabilitation care provided on May 16, 2022, to June 01, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service September 
13, 2022. 
 
You asked the Plan to pay for procedure code 76642. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says the number of units billed exceeds 
the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76642 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76642 billed for date of service September 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 24, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that the facility does not see the patient and cannot 
facilitate authorization. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the genetic testing 
provided on June 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an ILR (33285). 
 
You asked the Plan to pre-approve insertion of an ILR. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the request is 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 insertion of an ILR. Our reviewer says 
that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is no documentation provided to suggest a history of unexplained syncope, 
cryptogenic stroke or any other apparent indication for an ILR. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of an ILR have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of an ILR (33285).