Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for the eye exam (92012, computerized 
ophthalmic imaging (92134) eye drug injection (67028) and bevacizumab drug (J9035) provided on December 
8, 2021. 
 
You asked the Plan to waive the cost-sharing for the vision services. You say that you were billed more than 
you were expecting for these services, which you have had before. The Plan denied your request. The Plan says 
this claim was processed correctly, and your cost-sharing was assessed in accordance with your contract. 
 
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 $25 
copayment for each Medicare-covered vision care service. Your contract also says that you must pay 15% coinsurance for outpatient radiological diagnostic services and 20% coinsurance for each Medicare Part B 
prescription drug service. 
 
You have been asked to pay a $25 copayment for the eye exam and a $25 copayment for the eye drug 
injections. These services are each considered Medicare-covered vision care services. This means you have 
been asked to pay the correct amount for these services based on your contract with the Plan. 
 
You have been asked to pay $6.21 for the computerized ophthalmic imaging service, which falls within the 
outpatient radiological diagnostic services benefit category. The Provider billed the Plan $190 for this service, 
but the Plans discounted rate (from which your coinsurance is calculated) is $41.40. ($41.40 x 15% 
coinsurance = $6.21). This means you have been asked to pay the correct amount based on your contract with 
the Plan. 
 
You have been asked to pay a total of $28.16 for 20 mg of bevacizumab. Bevacizumab falls within the 
Medicare Part B prescription drug services benefit category. The provider billed the Plan a total of $500 for 
these services, but the Plans discounted rate is $140.82 ($140.82 x 20% coinsurance = $28.16). 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-sharing for the eye exam (92012, computerized 
ophthalmic imaging (92134) eye drug injection (67028) and bevacizumab drug (J9035) provided on December 
8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0861) with power 
tilt/recline and accessories 
 
You asked the Plan to pre-approve the requested group 3 power wheelchair with power tilt/recline and 
accessories.. You say that this specific chair and requested accessories are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not have a medical need for the multiple power options 
included with a K0861 Group 3 power wheelchair, and the electronic connection, expandable controller, and 
harness are not medically necessary. The enrollee would meet criteria for a Group 3 power wheelchair with no 
power options instead. 
 
The Plan follows Medicare rules. Medicare rules say group 3 power wheelchairs with multiple power options 
are only covered when medically necessary and certain specific criteria for the power options are met. 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 requested group 3 power wheelchair 
with power tilt/recline and accessories. Our reviewer says that the specific wheelchair requested is not 
medically necessary. Our physician reviewer found the enrollee has a neurologic disorder with functional 
deficits.  She meets criteria for use of a power mobility device. The documentation doesn't indicate that the 
enrollee requires multiple power options including power tilt, recline or leg elevations. The requested electrical 
accessories are therefore not medically necessary.  Furthermore, the documentation does not indicate that the 
enrollee has any pressure injuries or requires intermittent catheterization of the bladder.  
 
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 requested group 3 power wheelchair with power tilt/recline and accessories. 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power 
wheelchair (K0861) with power tilt/recline and accessories
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on December 17, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the home visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the home visit provided on December 17, 2021, by an out-of-
network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage (A0170). 
 
You asked the Plan to pre-approve additional transportation mileage. You say that you have a chronic disease, 
and you need to exceed the mileage limit to see your doctor. The Plan denied your request. The Plan says you 
are requesting an additional 31 miles for a total of 81 miles and your benefit only allows 50 miles. The Plan 
also says you have exceeded your benefit 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. The Plan covers up to 60 one-way trips and each one-way trip must not exceed 50 miles of driving 
distance.   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, trips over 50 miles 
are not covered. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation mileage (A0170).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 5, 2021. 
 
You asked the Plan to pay for the laboratory 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. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on October 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for continuous glucose monitor supplies 
provided on January 7, 2022, and February 7, 2022. 
 
You asked the Plan to waive the coinsurance for continuous glucose monitor supplies. You say that you have 
never had to pay a copayment before, and you cannot afford this. 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 durable medical equipment and supplies.  
 
 
 You have been asked to pay $47.86, which is 20% coinsurance of the allowed amount for continuous glucose 
monitor supplies on January 7, 2022, and February 7, 2022 ($239.29 allowed amount x 20% coinsurance = 
$47.86). You have been asked to pay a total of $95.72 ($47.86 coinsurance + $47.86 coinsurance = $95.72). 
Continuous glucose monitor supplies falls within the Durable Medical Equipment (DME) and Related 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 coinsurance for continuous glucose monitor 
supplies provided on January 7, 2022, and February 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chest X-ray (71045) provided on November 24, 2021. 
 
You asked the Plan to pay for a chest X-ray. You say that you have provided records to support the level of 
service. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a chest X-ray have not been met. Specifically, the Plan has documented that the claim at issue is a 
duplicate of a prior claim that has been processed and paid. Therefore, we decided that the Plan does not have 
to pay for a chest X-ray (71045) provided on November 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular cancer genomics (CGx) testing (CPT code(s): 
81408, 81292, 81321, and 81407) provided on November 3, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met.  Medicare denies 
coverage when a laboratory assays two or more genes in a patient in parallel. Those two or more genes will be 
considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be 
submitted for the panel. Therefore, we decided that the Plan does not have to pay for the molecular cancer 
genomics (CGx) testing (CPT code(s): 81408, 81292, 81321, and 81407) provided on November 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You have a past medical 
history of diabetes, atrial fibrillation, sick sinus syndrome, and hypertension and are living at home with 
functional decline and weakness. Medical problems are stable. There are no complex nursing or rehabilitation 
needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not 
a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office services (CPT code(s): 99204-25, 20604RT, and 
J3301) provided on May 19, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for the out-of-network services. You say that the claim should be paid. The Plan 
denied your request. The Plan says non-contracted providers referring by another non-contracted provider 
require authorization. The Plan states no approved authorization on file. 
 
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 office services (CPT code(s): 99204-25, 
20604RT, and J3301) provided on May 19, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services provided on November 24, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the claim was 
billed with an inappropriate place of service 22. 
 
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 records show that the claim in question was billed with place of service 21. 
The Plan has not provided documentation supporting its denial. Without supporting documentation, the Plan's 
denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the services provided on 
November 24, 2021.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a transthoracic echocardiography (C8928) 
provided on December 21, 2021. 
 
You asked the Plan to waive the copayment for the transthoracic echocardiography. You say that the services 
should be covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-
sharing applied correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for Outpatient hospital services.  
 
 
  You have been asked to pay a $250 copayment for the transthoracic echocardiography. Transthoracic 
echocardiograms fall 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 a transthoracic echocardiography (C8928) provided on December 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography, abdomen and pelvis (74176) 
provided on January 20, 2020 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the diagnostic service. You say that the services the enrollee received was 
appropriate and medically necessary for proper diagnosis and treatment of her acute and worsening abdominal 
pain. The Plan denied your request. The Plan says enrollees must receive their medical services from an in-
network provider with the exception being urgent or emergent services. Non-emergent services with non-
contracted providers require prior authorization before services being rendered. 
 
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 computed tomography, abdomen and pelvis 
(74176) provided on January 20, 2020 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing (0012M) provided on July 20, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M are non-covered 
for CxBladder testing.  
 
We looked at the file and Medicare rules. The CxBladder testing in this case was billed with code 0012M. 
Code 0012M is not covered for CxBladder testing. Based on this information, we decided that Medicare rules 
for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
CxBladder testing (0012M) provided on July 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for refill kit for implantable infusion pump (CPT code A4220) 
provided on November 12, 2021. 
 
You asked the Plan to pay for the item. You say that the claim should be paid. The Plan denied your request. 
The Plan says the item is not covered as 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. 
 
Our records indicate that procedure A4220, which has a status indicator of 'P' on the CMS Physician Relative Value File, is always bundled into payment for other services not specified and no separate payment is made 
per Medicare. Based on this information, we decided that Medicare rules for coverage of the item have not 
been met. Therefore, we decided that the Plan does not have to pay for refill kit for implantable infusion pump 
(CPT code A4220) provided on November 12, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a phlebectomy (37765). 
 
You asked the Plan to pre-approve the phlebectomy. You say that the procedure is medically necessary. The 
Plan denied your request. The Plan says that coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that treatments to eliminate the saphenous vein reflux will 
be considered medically necessary if the patient remains symptomatic after a six-week trial of conservative 
therapy and has reflux in a saphenous vein. 
 
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 phlebectomy. Our reviewer says 
that this procedure is medically necessary. Our physician reviewer found the documentation supports the 
medical necessity of the treatment in question. The patient has a painful varicose vein on the knee which is 
unlikely to respond to compression. There is satisfactory documentation that conservative efforts have been 
trialed and failed. The patient is status post previous ligation and stripping of the great saphenous vein and 
there is no evidence that the current varicosity communicates with a significantly refluxing truncal vein. The 
proposed procedure is limited in scope, focused on the most symptomatic area. Stab phlebectomy of the 
offending vein is both reasonable and medically 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 the phlebectomy have been met. Therefore, we decided that the Plan has to pre-
approve a phlebectomy (37765).  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82728, 83540, 83550, 
and 83970) provided on October 13, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the claim line denied against MultiPlan edits for proper coding standards 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The provider did not bill as required by Medicare coding regulations. Based on this information, we decided 
that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services (CPT code(s): 82728, 83540, 83550, and 83970) provided 
on October 13, 2021.