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

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 29, 2021. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 29, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency department visit provided on 
June 03, 2022. 
 
You asked the Plan to waive the copayment for an emergency department visit. You say that you should not be 
responsible to pay this. 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 an emergency department 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 an emergency 
department visit provided on June 03, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physical therapy (PT) services (97110) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the PT services. You say that you would like to go to this therapist for one-
on-one sessions. The Plan denied your request. The Plan says this service is not covered OON. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the physical therapy (PT) services (97110) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 13, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 an office visit provided on June 13, 2022, by an 
out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 73610, 73630, and 96372 provided on May 
16, 2022. 
 
You asked the Plan to pay for procedure codes 73610, 73630, and 96372. 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 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that procedure codes 73610, 73630, and 96372 are not supported in the medical record. Specifically, 
code 99284 (emergency department visit) was billed on the same date of service, with revenue code 450. This 
code has a status indicator of "V". Therefore, this makes codes 73610, 73630, and 96372 not separately 
payable. Therefore, we decided that the Plan does not have to pay for procedure codes 73610, 73630, and 
96372 provided on May 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on 
September 9, 2021. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you are disappointed in the 
lack of information and explanation regarding claim's "facility fees". You say that you are requesting an 
explanation of benefits and coverage for each charge that was billed regarding this procedure. 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 $295 
copayment for Medicare-covered surgery or other services provide to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges.  
 
 
  You have been asked to pay $242.59, which is less than the standard $295 copayment for an outpatient surgery. 
This item/service falls within Outpatient Surgery and Other Medical 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 an outpatient surgery provided on September 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture treatment. 
 
You asked the Plan to pre-approve acupuncture treatment. The Plan denied your request. The Plan says 
acupuncture treatment is not medically necessary.  
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, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. 
 
We looked at the file and Medicare rules. The rules say acupuncture treatment is only covered for the diagnosis 
of chronic low back pain (CLBP). There is insufficient information in the record to determine if Medicare rules 
for coverage of acupuncture treatment have been met. Specifically, the medical records submitted are very 
limited and do not document CLBP.  Based on this information, we decided that the rules for coverage of the 
acupuncture services have not been met. Therefore, we decided that the Plan does not have to pre-approve 
acupuncture treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a grab bar and a shower chair. 
 
You asked the Plan to pre-approve a grab bar and a shower chair. The Plan denied your request. The Plan says 
this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because 
they are not primarily medical in nature. The Plan must follow Medicare rules. Medicare rules say that shower 
chairs are not covered because they are not primarily medical in nature. 
 
While a grab bar and shower chair may be appropriate in this case, neither the Plan nor Medicare offers 
coverage of this item.  Therefore, we decided that the Plan does not have to pre-approve a grab bar and a 
shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the benralizumab injection provided on 
February 24, 2022. 
 
You asked the Plan to waive the cost share for the benralizumab injection. You say that you were not aware the 
injection would cost this much. 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% 
coinsurance for Part B drugs.  
 
You have been asked to pay a 20% coinsurance for Part B drugs for the benralizumab injection for a total of 
$1,007.40. This item/service falls within the Medicare Part B Prescription Drugs benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the cost share for the benralizumab injection provided on February 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lucentis. 
 
You asked the Plan to pre-approve Lucentis. You say that only Lucentis and Eylea have specific FDA approval 
for the enrollee's eye conditions. The Plan denied your request. The Plan says the enrollee has not tried and 
failed bevacizumab. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Lucentis. Our physician reviewer found 
that the enrollee has exudative age-related macular degeneration, left eye, with active choroidal 
neovascularization. The Plan requires a trial of bevacizumab before they will approve the requested drug, 
Lucentis. There is no indication that the enrollee has tried and failed the required drug. There is no indication 
that the Plan's required drug would likely be less effective or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lucentis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Lucentis.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 screening (0202U) provided to the enrollee 
on May 5, 2022. 
 
You asked the Plan to pay for the COVID-19 screening. You say that this service was medically necessary and 
that additional payment is due. The Plan denied your request. The Plan says that the denial of COVID testing 
utilizing CPT code 0202U was appropriate given the clinical scenario and the guidance presented. 
 
The Plan must follow Medicare rules. Medicare rules say CPT 0202U is not covered. 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Medicare does not provide coverage for the denied code. Based on 
this information, we decided that Medicare rules for coverage of the COVID-19 screening have not been met. 
Therefore, we decided that the Plan does not have to pay for the COVID-19 screening (0202U) provided to the 
enrollee on May 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit for an orthopedics second opinion to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the office visit. 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 they are non-
emergent and can be provided in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit for an orthopedics second opinion to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service February 13, 
2022. 
 
You asked the Plan to pay for procedure code 93010. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 93010 is bundled into payment for code 51702. 
 
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 93010 
is a column II code to column I code 51702. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met.  
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. 
 
Therefore, we decided that the Plan does not have to pay for procedure code 93010 billed for date of service 
February 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (96156) provided on April 27, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid 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. 
 
We find that CPT code 96156 is not supported in the medical record. Specifically, the claim was not billed with 
a valid diagnosis code for this service. Based on this information, we decided that Medicare rules for coverage 
of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for 
physician services (96156) provided on April 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Emgality Pen. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Emgality Pen.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the colonoscopy with tissue removal 
provided on April 20, 2022. 
 
You asked the Plan to waive the copayment for the colonoscopy with tissue removal. You say that your EOC 
states there is no cost share for a covered colorectal cancer screening exam. 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 $50 
copayment for each outpatient surgery.  
 
Records show that tissue was removed during your colonoscopy. Therefore, the colonoscopy is considered 
diagnostic and not a screening, and the outpatient surgery copayment applies. You have been asked to pay a 
$50 copayment the colonoscopy with tissue removal. 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 the colonoscopy with tissue removal provided 
on April 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder testing rendered on December 29, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing is not covered. 
 
The Plan must follow Medicare rules. The rules say that the Cxbladder testing is non-covered. 
 
We looked at the file and Medicare rules. The test at issue is Cxbladder. This test is not covered by Medicare. 
Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on December 29, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-rays on April 14, 2022. 
 
You asked the Plan to waive the copayment for x-rays. You say that you dont think you should pay for an x-
ray for knee surgery since this is how they see if the parts they put in are in the right place. 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 $35 
copayment per day, per provider, for Medicare-covered x-ray services. Covered services include, but are not 
limited to X-rays. 
 
You have been asked to pay a $35 copayment for x-rays. 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 x-rays on April 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a debridement procedure provided on 
February 2, 2022, February 9, 2022, February 16, 2022, and February 23, 2022. 
 
You asked the Plan to waive the copayment for a debridement procedure. You say that no one notified you of 
this high copayment. You were told it would be $10. 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 outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers. You had four visits, at $150 per visit, equaling a $600 copayment ($150 x 4 = 
$600). 
 You have been asked to pay a $150 copayment for a debridement procedure. This item/service falls within the 
outpatient surgery and other medical 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 a debridement procedure 
provided on February 2, 2022, February 9, 2022, February 16, 2022, and February 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for injections on June 06, 2022. 
 
You asked the Plan to waive the copayment for injections. You say that the copayment should be $10. 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 Medicare-covered outpatient hospital surgery services. Covered services include, but are not 
limited to services in an emergency department or outpatient clinic, such as observation services or outpatient 
surgery. 
 
 
 
 
 
 You have been asked to pay a $150 copayment for injections. 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 injections on June 
06, 2022.