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

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 19, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an arthrocentisis provided on May 31, 
2022. 
 
You asked the Plan to waive the copayment for an arthrocentisis. You say that you feel you should not be 
paying anything for the service and would like the copayment 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 $250 
copayment for outpatient procedure. 
 
You have been asked to pay a $250 copayment for an arthrocentisis. This item/service falls within the 
outpatient procedure 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 arthrocentisis 
provided on May 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom shoe inserts. 
 
You asked the Plan to pre-approve foot orthotics. You say that you would pay more in physical therapy than 
for the shoe inserts. The Plan denied your request. The Plan says the services are not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve custom shoe inserts.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient hospital facility visits provided 
from April 5, 2022, to May 10, 2022. 
 
You asked the Plan to waive the copayments for outpatient hospital facility visits. You say that the provider 
billed the procedures using incorrect code causing an outpatient surgery copayment to occur. You say you 
would like this to be processed correctly with no 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 $290 
copayment for each Medicare-covered outpatient hospital facility visit.  
 
You have been asked to pay $1,160 for outpatient hospital facility visits ($290 per visit x 4 visits = $1,160). 
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 copayments for outpatient hospital facility visits provided from April 5, 2022, to May 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections provided on April 14, 2022, and 
April 15, 2022. 
 
You asked the Plan to waive the coinsurance for injections. You say that you were told by the provider there 
would only be a $35 copayment for the services, but you were not aware of the coinsurance. 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 20% 
coinsurance for injections or durable medical equipment and prosthetic/orthotics if supplied by the physician, 
in addition to office visit copay.  
 
 
  You have been asked to pay $313.62, which is 20% of the allowed amount for both injections ($784.04 allowed 
per injection x 20% = $156.81 per injection). 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 coinsurance for injections 
provided on April 14, 2022, and April 15, 2022.  
 
Your complaint about not being informed of the coinsurance amount for the services rendered is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the specialist services provided on 
February 18, 2022, to March 11, 2022. 
 
You asked the Plan to reduce the copayment for the specialist services. You say that you cannot afford these 
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 
$147.06 copayment for physician/practitioner services, including doctors office visits (specialist visits). 
 
You have been asked to pay a $147.06 copayment for the specialist services. This item/service falls within the 
physician/practitioner services, including doctors office visits (specialist 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. The allowed amount for each of the 
three specialist visits is $49.02. Since this is less than the $50 copayment per the EOC, you are only responsible 
for the lesser amount. The total for all three visits is $147.06 ($49.02 copayment x 3 visits = $147.06).Therefore, we decided that the Plan does not have to reduce the copayment for the specialist services 
provided on February 18, 2022, to March 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral appliance (E0486) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve an oral appliance (E0486) to be provided by an OON provider. You say that 
you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested 
services are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network 
providers available to you that can provide the oral appliance (E0486) you are requesting. 
 
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 oral appliance (E0486) to be provided 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 services on May 31, 2022. 
 
You asked the Plan to waive the copayment for outpatient services. 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 $200 
copayment for each outpatient surgical service. 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 $200 copayment for outpatient services. 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 outpatient 
services on May 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the specialist office visit provided on May 
31, 2022. 
 
You asked the Plan to waive the coinsurance for the specialist office visit. You say that you feel the Plan 
should cover all costs. 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 20% 
coinsurance for services obtained from a specialist. 
 
You have been asked to pay 20% coinsurance for the specialist office visit. This item/service falls within the 
services obtained from a specialist 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. The allowed amount for the specialist office visit is $129.76, and the 20% 
coinsurance applied is $25.85. Therefore, we decided that the Plan does not have to waive the coinsurance for 
the specialist office visit provided on May 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT scan of the thorax provided on April 
07, 2022. 
 
You asked the Plan to waive the copayment for the CT scan of the thorax. You say that the scan should be paid 
in full. 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 
$337.59 copayment for outpatient diagnostic tests and therapeutic services and supplies (CT scan). 
 
You have been asked to pay a $337.59 copayment for the CT scan of the thorax. This item/service falls within 
the outpatient diagnostic tests and therapeutic services and supplies (CT scan) 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. The allowed amount for the CT scan is 
$337.59. Since this amount is less than the $350 copayment per the EOC, you are only responsible for the 
lesser amount. Therefore, we decided that the Plan does not have to waive the copayment for the CT scan of 
the thorax provided on April 07, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service January 19, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service January 19, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on April 12, 
2022. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you have never had to pay a 
$15 copayment for lab work before and you feel you shouldnt have to pay 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 $15 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $15 copayment for laboratory services. This item/service falls within the 
outpatient diagnostic 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 laboratory 
services provided on April 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durable medical equipment (DME) Supplies (E0651 
E0667) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the DME. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items 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 
durable medical equipment (DME) Supplies (E0651 E0667 ) to be provided by an out-of-network (OON) 
provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy on February 28, 2022, to 
April 19, 2022. 
 
You asked the Plan to waive the copayments for physical therapy. 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 $40 
copayment for each Medicare-covered physical therapy and speech-language therapy visit. Covered services 
include physical therapy, occupational therapy, and speech language therapy. There were 10 services. $40 x 10 
= $400. Therefore, results in the total cost sharing amount of $400.  
 
 
 
 You have been asked to pay a $40 copayment for each physical therapy. This item/service falls within the 
Outpatient rehabilitation 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 copayments for 
physical therapy on February 28, 2022, to April 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for office visit on March 21, 2022, to April 
21, 2022. 
 
You asked the Plan to waive the copayments for office visit. 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 $65 
copayment for out-of-network provider and professional services at primary care physicians (PCP) office and 
specialists office. Covered services include consultation, diagnosis, and treatment by a specialist. There were 2 
visits. $65 x 2 = $130. Therefore, results in the total cost sharing amount of $130.  
 
 
 
 You have been asked to pay a $65 copayment for each office visit. This item/service falls within the 
Physician/practitioner services, including doctor's 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 copayments for office visit on March 21, 2022, to April 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Soliris. 
 
You asked the Plan to pre-approve Soliris. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Soliris. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a history of myelodysplastic syndrome with non-autoimmune hemolytic 
anemia likely with mild thrombotic microangiopathic anemia. Based on the medical records provided and the 
Medicare-approved major drug compendia there is no documentation that the Soliris at issue in this case meets 
all Medicare criteria for medically reasonable and necessary for the patient. Provided records do not document 
that the patient has a medically-accepted indication for use of the Soliris. According to the Medicare-approved 
major drug compendia non-autoimmune hemolytic anemia is not a medically-accepted indication for use of 
Soliris. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Soliris have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Soliris.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the hospital observation care provided on 
March 31, 2022. 
 
You asked the Plan to reduce the copayment for the hospital observation care. You say that you were informed 
that your copayment would only be $90. 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 $200 
copayment for outpatient hospital observation services. 
 
You have been asked to pay a $200 copayment for the hospital observation care. This item/service falls within 
the outpatient hospital observation 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 reduce the copayment 
for the hospital observation care provided on March 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the requested PCD is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria 
for the requested PCD. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652).