Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for intravitreal injection of a pharmacologic 
agent and aflibercept injection aflibercept injection provided on July 21, 2022. 
 
You asked the Plan to waive the coinsurance for  injection. You say that you should not be responsible for the 
cost share for the 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 $30 
copayment for medical care or surgery in a Specialty Physicians office and 20% coinsurance for each 
Medicare-covered Part B drug. 
  You have been asked to pay $389.30 for intravitreal injection of a pharmacologic agent and aflibercept 
injection. The allowed amount is $1,765.50 (20% x $1,765.50=$359.30 + $30 copayment = $389.30). This 
intravitreal injection of a pharmacologic agent and aflibercept injection falls within the Medicare Part B 
prescription drugs and Physician/Practitioner services, including doctors office visit 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  intravitreal injection of a pharmacologic agent and 
aflibercept injection aflibercept injection provided on July 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
and supplies (K0553). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM and supplies. You say that you are taking three 
types of diabetes medications and need the requested supplies. The Plan denied your request. The Plan says you 
do not meet coverage criteria for the requested CGM and supplies. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre continuous glucose monitor (CGM) and supplies (K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
documentation does not support that the requested item is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a home ventilator. The compliance reports indicate the enrollee is not using the 
device enough to be effective. The enrollee has heart failure with preserved ejection fraction (HFpEF), 
pulmonary hypertension, and pulmonary scarring from prior radiation therapy. The enrollee was recently 
hospitalized with COVID-19 pneumonia and exacerbation of HFpEF. Arterial blood gas showed mild carbon dioxide retention. There is no diagnosis of COPD, thoracic restrictive disease, or neuromuscular disease. The 
documentation does not support that the enrollee meets Medicare criteria for a home ventilator. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic test provided on August 04, 2021, by an out-of-
network (OON) provider. 
 
 
 
 
 
 You asked the Plan to pay for diagnostic test. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says if the enrollee needs medical care that Medicare requires our plan to cover and the 
providers in our network cannot provide this care, the enrollee can get this care from an out-of-network 
provider. In this situation, the enrollee will pay the same as they would pay if they got the care from a network 
provider. Similar to the referral requirements for care received from network providers (see Chapter 3, Section 
2.3), the enrollee must get a referral from your primary care provier (PCP) prior to getting care from out-of-
network providers. If the enrollee does not get a referral, they will have to pay the full cost of any services they 
receive. A referral or prior authorization is never required for emergency care, urgently needed care when 
network providers are unavailable, and dialysis for members with ESRD who are temporarily out of the service 
area. 
 
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 diagnostic test provided on August 04, 2021, by an 
out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a duplex scan provided on April 14, 2022. 
 
You asked the Plan to waive the copayment for a duplex scan. You say that you did not know you would have 
a seperate copayment at another facility. 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 $175 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $175 copayment for a duplex 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 a duplex scan provided on April 14, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on June 01, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you are appealing the copayment 
for the outpatient diagnostic testing as you feel you should not owe it. 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 outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $100 copayment for an ultrasound. 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 an ultrasound provided on June 01, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hepatobiliary system imaging provided on 
June 07, 2022. 
 
You asked the Plan to waive the copayment for hepatobiliary system imaging. You say that you believe you do 
not owe the copayment. 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 advanced imaging. 
 
You have been asked to pay a $225 copayment for hepatobiliary system imaging. This item/service falls within 
the advanced imaging 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 
hepatobiliary system imaging provided on June 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revascularization services represented by codes 37225, 
37226, 37227, and 37228. 
 
You asked the Plan to pre-approve the revascularization services. You say that the enrollee would benefit from 
a left lower extremity arteriogram with possible intervention because of his high-risk medical history and 
arterial doppler showing evidence of progressive peripheral arterial occlusive disease to improve his quality of 
life. The Plan denied your request. The Plan says the requested procedures are generally no considered 
appropriate if the reason for treatment is walking discomfort. The Plan says that there is no evidence in the 
chart that the enrollee has been in a supervised exercise program of the equivalent. The Plan says that there is 
no evidence in the chart that the enrollee has tried the medicine Pletal for at least 12 weeks. 
 
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 revascularization services. Our 
reviewer says that the requested revascularization services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the documentation does not support the medical necessity 
of the treatments in question.  There are numerous inconsistencies throughout the enrollee's evaluation from visit to visit.  On September 13, 2022, it was documented that he was asymptomatic from an arterial disease 
standpoint and the pulse examination was nonsensical.  The plan was to schedule for left lower extremity 
arteriogram and possible intervention.  On September 13, 2022, he was documented to have no difficulty 
walking or climbing stairs.  On August 8, 2022, it was documented that walking makes his legs feel better and 
pedal pulses were 2+ bilaterally.  A more recent note describes that the enrollee cannot walk more than 25 feet 
and has an uninterpretable pulse examination noting both palpable pedal pulses and nonpalpable pedal pulses.  
However, the documentation is fairly consistent in that there does not appear to be demonstration of limb 
threat. The documentation does not provide sufficient clarity on which to overturn the health plan 
determination on the basis of medical necessity. 
 
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 revascularization services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve revascularization services represented by codes 37225, 37226, 37227, and 
37228.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram provided on May 25, 
2022. 
 
You asked the Plan to waive the copayment for an electrocardiogram. You say that you were told the office 
visit copayment was waived 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 $75 
copayment for each Medicare-covered diagnostic procedure and test. 
 
You have been asked to pay a $75 copayment for an electrocardiogram. This item/service falls within the each 
Medicare-covered diagnostic procedure and test 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 an electrocardiogram provided on May 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on April 22, 2022. 
 
You asked the Plan to pay for the medical services. You say that the patient was not enrolled in hospice on this 
date of service. The Plan denied your request. The Plan says Original Medicare, not the Plan, is responsible for 
this bill. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 The enrollee ended Medicare Hospice benefits on April 13, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for medical services 
provided on April 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a computed tomography scan provided on 
June 28, 2022. 
 
You asked the Plan to reduce the copayment for a computed tomography scan. You say that you were told the 
copayment would be less 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 $150 
copayment for advanced imaging services that are provided in an outpatient hospital facility. 
 
You have been asked to pay a $150 copayment for a computed tomography scan. This item/service falls within 
the advanced imaging services that are provided in an outpatient hospital facility 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 computed tomography scan provided on June 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth service provided on June 6, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the telehealth service. You say that you would like the claim to be 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. Also, the service rendered was not 
urgent or emergent. 
 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 telehealth service provided on June 6, 2022, by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery on May 25, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you want to appeal the amount 
being charged. 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 $370 
copayment per day for other outpatient procedures and services, including, but not limited to, diagnostic and 
therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical 
center. If you are having surgery in a hospital facility, you should check with your provider about whether you 
will be an inpatient or outpatient. Unless the provider writes an order to admit you as an inpatient to the 
hospital, you are an outpatient and pay the cost-sharing amounts for outpatient surgery. Even if you stay in the 
hospital overnight, you might still be considered an outpatient. 
 You have been asked to pay a $370 copayment for outpatient surgery. This item/service 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 outpatient surgery on May 25, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service January 11, 
2022. 
 
You asked the Plan to pay for procedure code 93042. You say that the code is separately billable. The Plan 
denied your request. The Plan says no modifiers are allowed with this code pair. 
 
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 93042 is a column II code to column I code 99291 with a modifier 
indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 93042 
billed for date of service January 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 28, 2022. 
 
You asked the Plan to pay for the lab services. You say that the place of service was billed correctly. The Plan 
denied your request. The Plan says the procedures require modifier 26. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT codes 88341, 88342, 88360, and 88381 were not billed with a modifier suitable for payment. 
Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for the lab services provided on February 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99291) provided on October 11, 2021. 
 
You asked the Plan to pay for the critical care services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the billed service. 
 
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 99291 is a Critical Care Visit, 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not detail how 
much time was spent on this service. Based on this information, we decided that Medicare rules for coverage of 
the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for 
critical care services (99291) provided on October 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services billed for date of service May 18, 
2022. You asked the Plan to pay for the billed services. You say that the documentation supports the level of care 
billed. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in 
the medical record. Specifically, the records provided do not document the total time that critical care services 
were furnished. Based on this information, we decided that Medicare rules for coverage of the billed services 
have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services billed 
for date of service May 18, 2022.