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

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (ECG) (93010) 
provided on November 30, 2021. 
 
You asked the Plan to waive the copayment for the ECG. 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 $10 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $8.01 copayment for the ECG as the allowed amount for these services is lower 
than the contracted rate. ECGs fall 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 electrocardiogram (ECG) 
(93010) provided on November 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (codes 82728, 83540, and 83550) billed for date 
of service September 28, 2021. 
 
You asked the Plan to pay for the lab services. You say that you do not have a contract in place to include these 
labs in the dialysis rate, so these lab services should be paid. The Plan denied your request. The Plan says these 
services are not separately payable for an End Stage Renal Disease (ESRD) patient. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services furnished ESRD patients are 
included in the ESRD Prospective Payment System as Part B services and are not paid separately. If the lab 
services are furnished for reasons other than for the treatment of ESRD, the provider should bill separately 
using the AY modifier. 
 
In this case, the patient is an ESRD patient.  You did not bill these lab services with an AY modifier to indicate 
that they were furnished for any reason other than ESRD treatment.   According to Medicare rules, these lab services are not separately payable as billed. Therefore, we decided that 
the Plan does not have to pay for lab services (codes 82728, 83540, and 83550) billed for date of service 
September 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that the injection is needed and was covered 
in the past. The Plan denied your request. The Plan says this is not medically necessary because the records do 
not indicate the levels for the proposed treatment or any documentation of the pain relief from prior injection 
procedures. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections are coverable for patients who 
meet all of the criteria outlined in the Local Coverage Determination as stated in the rules section of this letter.  
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 facet joint injections. Our reviewer says 
that the requested facet joint injection is not medically necessary. Our physician reviewer found the lack of 
documentation of the effectiveness of the prior intervention precludes the approval of further interventions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110) and complete 
denture - mandibular (D5120). 
 
You asked the Plan to pre-approve a complete upper and lower denture. You say that the enrollee lost her 
dentures and needs new ones. The Plan denied your request. The Plan says the enrollee will exceed the 
frequency limit for this service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a complete 
upper and lower denture once every five plan years.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that upper and lower 
dentures were previously covered on January 21, 2021.  Based on this information, we decided that the Plan's frequency limit for coverage of a complete upper and 
lower denture will be exceeded with the requested service. Therefore, we decided that the Plan does not have to 
pre-approve a complete denture - maxillary (D5110) and complete denture - mandibular (D5120).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that the records provided support the need for SNF 
care. The Plan denied your request. The Plan says needs are custodial in nature. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee 
does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 
setting. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (codes 82728, 83540, and 83550) billed for date 
of service October 20, 2021. 
 
You asked the Plan to pay for the lab services. You say that you do not have a contract in place to include these 
labs in the dialysis rate, so these lab services should be paid. The Plan denied your request. The Plan says these 
services are not separately payable for an End Stage Renal Disease (ESRD) patient. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services furnished ESRD patients are 
included in the ESRD Prospective Payment System as Part B services and are not paid separately. If the lab 
services are furnished for reasons other than for the treatment of ESRD, the provider should bill separately 
using the AY modifier. 
 
In this case, the patient is an ESRD patient.  You did not bill these lab services with an AY modifier to indicate 
that they were furnished for any reason other than ESRD treatment.   According to Medicare rules, these lab services are not separately payable as billed. Therefore, we decided that 
the Plan does not have to pay for lab services (codes 82728, 83540, and 83550) billed for date of service 
October 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99215) and the prolonged office or other 
outpatient evaluation and management service (G2212 x 3) rendered by the out-of-network (OON) provider on 
September 17, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the office visit (99215) and the prolonged office or other outpatient evaluation 
and management service (G2212 x 3) rendered by the out-of-network (OON) provider on September 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) and the chiropractic manipulative 
treatment (98942) rendered by the out-of-network (OON) provider on October 29, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the office visit (99203) and the chiropractic manipulative treatment (98942) 
rendered by the out-of-network (OON) provider on October 29, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy (90837) provided on December 3, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. You say that this provider is an in-network provider, and 
previous claims for this patient have been paid. The Plan denied your request. The Plan says this provider is not 
a network provider with the Plan, and they have also determined that these services are not urgent or emergent, 
nor were they approved in advance. 
 
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 psychotherapy (90837) provided on December 3, 
2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray (E0570) provided on December 
15, 2021. 
 
You asked the Plan to waive the copayment for the x-ray. 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 $100 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $76.86 copayment for an x-ray, which is less than the standard $100. x-rays fall 
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 x-ray (E0570) provided on December 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Nebulizer with compressor (EO570) 
provided on October 23, 2021. 
 
You asked the Plan to waive the coinsurance for the Nebulizer with compressor. You say that the item 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 item 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 20% 
coinsurance for Durable medical equipment (DME) and related supplies.  
 
 
  You have been asked to pay a 20% coinsurance for the Nebulizer with compressor (allowed is $5.89 x 20% = 
$1.18), the record indicates that this coinsurance will be a monthly charge for this item. Nebulizers fall 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 a Nebulizer with compressor (EO570) provided on October 23, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF admission. You say that SNF admission is medically necessary. The 
Plan denied your request. The Plan says SNF admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the patient has no identifiable skilled 
nursing needs. While she does have skilled therapy needs, she does not require therapy daily on an inpatient 
basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: Other
Decision: Favorable

 
We decided that the Plan has to pre-approve a Kerecis Omega3 skin substitute 
 
You asked the Plan to pre-approve the Kerecis Omega3 skin substitute. You say that this product is approved 
and payable by Medicare. The Plan denied your request. The Plan says that no information regarding adequate 
circulation to the wound is available and the size of lesion is not yet known. 
 
The Plan follows Medicare rules. Medicare rules say that application of a skin substitute graft for lower 
extremity chronic wound is coverable in the presence of a full thickness skin loss ulcer that is the result of 
abscess, injury or trauma that has failed to respond to appropriate control of infection, foreign body, tumor 
resection, or other disease process for a period of 4 weeks or longer. 
 
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 Kerecis Omega3 skin substitute. 
Our reviewer says that the patient meets criteria for the Kerecis Omega3 skin substitute. Our physician 
reviewer found the patient has a full thickness skin loss ulcer that is the result of abscess, injury or trauma that 
has failed to respond to appropriate control of infection, foreign body, tumor resection, or other disease process 
for a period of 4 weeks or longer. 
 
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 Kerecis Omega3 skin substitute have been met. Therefore, we decided that 
the Plan has to pre-approve a Kerecis Omega3 skin substitute  
 
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 deductible for the insertion of a bladder catheter provided 
on December 6, 2021. 
 
 
You asked the Plan to waive the deductible for the insertion of a bladder catheter. You say that the services 
should be covered as you disagree with the charges. 
 The Plan denied your request. The Plan says the deductible 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. Your 
contract with the Plan says that there is a $500 deductible which applies to Durable medical equipment (DME) 
and related supplies.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category Durable 
medical equipment (DME) and related supplies. The Plan has followed Medicare rules by clearly disclosing in 
the contract that there is a $500 deductible which applies to Durable medical equipment (DME) and related 
supplies. This cost sharing is a contractual obligation that had not been met at the time the insertion of a 
bladder catheter was received on December 6, 2021. Therefore, we decided that the Plan does not have to 
waive the deductible for the insertion of a bladder catheter provided on December 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99211) rendered by the out-of-network 
(OON) provider on December 1, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99211) rendered by the out-of-network (OON) provider on  
December 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the 
lumbar spine provided on December 17, 2021. 
 
You asked the Plan to waive the copayment for the MRI. You say that the nearest in-network providers were 
50-60 miles away. 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 a $150 
copayment per day, per provider, for diagnostic radiology services.  
 
You have been asked to pay a $150 copayment for the MRI. Please note that this is the in-network rate. The 
MRI 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 magnetic resonance imaging (MRI) of the lumbar spine 
provided on December 17, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound of the head and neck (76536) 
provided on November 9, 2021. 
 
You asked the Plan to waive the copayment for an ultrasound of the head and neck. You say that you do not 
understand why the Plan refused payment for the test when it was ordered to rule out a problem with the 
thyroid. The Plan denied your request. The Plan says you were 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 a $160 
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic).  
 
You have been asked to pay $104.52, which is less than the $160 copayment for an ultrasound of the head and 
neck. An ultrasound of the head and neck 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 of the head 
and neck (76536) provided on November 9, 2021.