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

 
We decided that the Plan does not have to pay for lab work provided on August 4, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for lab work. You say that you did these labs in good faith and under medical 
necessity. The Plan denied your request. The Plan says there was no preauthorization by a primary care 
provider (this is different than a referral) for an out-of-network (OON) provider or facility, and this was not an 
emergency. Therefore, the decision is upheld. 
 
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 lab work provided on August 4, 2022, by an out-
of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visits provided on July 29, 2022, to 
August 18, 2022. 
 
You asked the Plan to waive the copayment for office visits. You say that you never saw these providers on 
these dates of service and feel you should not owe the copayments. 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 $25 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $25 copayment for office visits. This item/service falls within the 
physician/practitioner services, including doctors 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.  Therefore, we decided that the Plan does not have 
to waive the copayment for office visits provided on July 29, 2022, to August 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that it was medically necessary to treat the enrollee and 
you would like the claim paid. The Plan denied your request. The Plan says the rendering provider is an OON 
provider and there was no approved authorization. 
  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on April 14, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intervertebral disc percutaneous injection of 
allogeneic cellular and/or tissue-based product (0627T). 
 
You asked the Plan to pre-approve an intervertebral disc percutaneous injection. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 an intervertebral disc percutaneous 
injection. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is little evidence in the medical literature to suggest 
that this is an appropriate procedure for your back pain. It is not an accepted standard of medical practice for 
the diagnosis or treatment of back pain. The requested injection of allograft (in this case, VIA Disc NP) into the 
intervertebral disc for the treatment of degenerative disc disease, is considered experimental and 
investigational. VIA Disc is considered investigational and not medically necessary for the treatment of 
degenerative disc disease. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an intervertebral disc percutaneous injection have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an intervertebral disc percutaneous injection of allogeneic 
cellular and/or tissue-based product (0627T).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility services on March 
3, 2022, to March 18, 2022. 
 
You asked the Plan to waive the copayment for skilled nursing facility services. You say that you would like to 
appeal the cost share. The Plan denied your request. The Plan says this cost sharing was charged correctly, and 
that the member utilized 15 SNF days in February. 
 
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 for days 
1-20, there's a $0 copayment per day, per admission. For days 21-100, there's a $184 copayment per day, per 
admission for skilled nursing facility services. The total cost share is $1,840. 
 
You have been asked to pay for days 1-20, there's a $0 copayment per day, per admission. For days 21-100, 
there's a $184 copayment per day, per admission for skilled nursing facility services. 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. Therefore, we decided that the Plan does not have to waive the copayment 
for skilled nursing facility services on March 3, 2022, to March 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 4, 2021, to 
October 7, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
services at issue have been billed correctly. The Plan denied your request. The Plan says the DRG billed is not 
appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code, J96.01, defined as Acute 
respiratory failure with hypoxia. 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 pay for the inpatient 
hospital services at the DRG originally billed. Our reviewer says that the inpatient hospital services at issue do 
not meet criteria for payment at the DRG originally billed. Our physician reviewer found that there is no 
clinical or laboratory evidence of acute respiratory failure with hypoxia. The available records do not support 
DRG 189 and principal diagnosis code J96.01.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on October 4, 2021, to October 7, 2021, at the DRG originally billed.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a K3 flex walk system (L5981), axial rotation unit (L5984), and 
vertical shock reducing pylon (L5988). 
 
You asked the Plan to pre-approve a K3 flex walk system, axial rotation unit, and vertical shock reducing 
pylon. You say that the services are necessary. The Plan denied your request. The Plan says that based on the 
documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are covered when specific 
criteria 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 a K3 flex walk system, axial rotation 
unit, and vertical shock reducing pylon. Our reviewer says that the services are medically necessary. Our 
physician reviewer found the documentation provided by both the enrollees prosthetist and physician indicate 
that the enrollee is a K3 level ambulator. He walks long distances, with variable cadence, up and down stairs, 
on uneven ground and in the community. He can no longer use his existing prosthetic foot/ankle due to weight 
loss and it requires replacement. Therefore, the K3 flex walk system, axial rotation unit, and vertical shock 
reducing pylon are 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 a K3 flex walk system, axial rotation unit, and vertical shock reducing pylon 
have been met. Therefore, we decided that the Plan has to pre-approve a K3 flex walk system (L5981), axial 
rotation unit (L5984), and vertical shock reducing pylon (L5988).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on July 22, 
2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you thought you would not 
have a 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 $45 
copayment for physician/practitioner services/.  
 
You have been asked to pay a $45 copayment for specialist office visit. This item/service falls within the 
physician/practitioner 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 
specialist office visit provided on July 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided on July 03, 
2022, to July 20, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that the copayment is so 
expensive, you cannot afford to pay the bill. 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 $160 
copayment for Inpatient hospital care. 
 
You have been asked to pay a $160 copayment for inpatient hospital stay. 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 inpatient 
hospital stay provided on July 03, 2022, to July 20, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for date of service 
October 29, 2020. 
 
You asked the Plan to pay for procedure codes 99601 and 99602. You say that you would like this claim to be 
reprocessed for correct payment. The Plan denied your request. The Plan says the billed codes are invalid for 
Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 
 
 We find that procedure codes 99601 and 99602 have Status Indicators of I on the Physician Fee Schedule. This 
means that procedure codes 99601 and 99602 are not valid for Medicare purposes. Based on this information, 
we decided that Medicare rules for coverage of procedure codes 99601 and 99602 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for date 
of service October 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on March 04, 2022, to May 27, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you want to appeal the amount being charged. The Plan 
denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of our plans network) will not be 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 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 office visit provided on March 04, 2022, to May 
27, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 27, 2022, by an OON 
provider. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee requested for the nail to be 
tested for fungus and be treated as the infection was getting worse. The Plan denied your request. The Plan says 
the out-of-network services were not authorized. 
 
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 laboratory services provided on May 27, 2022, by 
an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a foot procedure provided on February 7, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a foot procedure. You say that we depend upon the hospital staff to verify 
eligibility and to obtain the proper authorization from the beneficiary's Plan. The Plan denied your request. The 
Plan says there was no preauthorization by a primary care provider (this is different than a referral) for an out-
of-network (OON) provider or facility, and this was not an emergency. Therefore, the decision is upheld. 
 
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 a foot procedure provided on February 7, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound debridement services provided on July 6, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound debridement services. You say that it was medically necessary to treat 
the enrollee and you would like the claim processed for payment. The Plan denied your request. The Plan says 
the rendering provider is an OON provider and there was no referral from an in-network provider or an 
approved authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the wound debridement services provided on July 
6, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Estradiol. 
 
You asked the Plan to pre-approve Estradiol. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Estradiol.  
 
Benefits for Estradiol 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you would like the claim reprocessed for payment. 
The Plan denied your request. The Plan says the rendering provider is an OON provider and there was no 
referral from an in-network provider or an approved authorization. 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 an office visit provided on July 11, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hearing test provided on July 22, 2022. 
 
You asked the Plan to waive the copayment for hearing test. You say that you feel the copayment 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 $40 
copayment for hearing services.  
 
You have been asked to pay a $40 copayment for hearing test. This item/service falls within the hearing 
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 hearing test provided on 
July 22, 2022.