Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator provided from January 25, 2022, to 
March 25, 2022. 
 
You asked the Plan to pay for the services provided. You say that the enrollee account has not met the rental 
cap limit. The Plan denied your request. The Plan says the rental cap has been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and the rules. The records show that the Plan has provided 36 rental payments for the 
enrollees oxygen equipment. Based on this information, we decided that Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for the oxygen concentrator provided from 
January 25, 2022, to March 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for dialysis services provided from April 2, 
2022, to April 30, 2022. 
 
You asked the Plan to waive the coinsurance for dialysis services. You say that you cannot afford this cost-
share. The Plan denied your request. The Plan says the coinsurance applied was correct. 
 
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 each Medicare-covered renal dialysis service with an in-network provider or when you are 
outside of the plans service area. The allowed amount of each claim is $299, resulting in a coinsurance amount 
of $59.80 per date of service ($299 x 20%). 
 
You have been asked to pay $777.40 for 13 dialysis services ($59.80 per day x 13) received from April 2, 
2022, to April 30, 2022. Dialysis services fall within the Services to Treat Kidney Disease 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 dialysis services provided from April 2, 2022, 
to April 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 28, 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 for 
payment. 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 April 28, 2022, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on January 4, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for an x-ray. 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 it was determined these 
services can be received 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 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 x-ray provided on January 4, 2022, by an out-
of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
February 23, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you cannot afford this 
copayment. The Plan denied your request. The Plan says you were charged this cost sharing 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 $195 
copayment for each ambulance trip. You had one ambulance trip. The Plan charged you $195 for these 
services. 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 ambulance services provided on February 
23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a static progressive stretch knee device provided on March 
26, 2022, by an OON provider. 
 
You asked the Plan to pay for a static progressive stretch knee device. You say that the claim was denied for 
authorization, but the provider obtained authorization 147774091 that covers this service.  The Plan denied 
your request. The Plan says authorization 147774091 was for October 01, 2021 and termed on November 30, 
2021. The plan says the out-of-network services were not authorized for this date of service. 
 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 static progressive stretch knee device provided 
on March 26, 2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for renal dialysis performed March 2, 2022, to 
March 30, 2022.  
 
You asked the Plan to waive the copayment for renal dialysis. You say that you cannot afford to pay this cost 
share. The Plan denied your request. The Plan says the cost share has been applied 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 renal dialysis.  
 
You have been asked to pay $1043.51($80.27x13=$1043.51) for renal dialysis. Renal dialysis falls within the 
Services To Treat Kidney Disease 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 
renal dialysis performed March 2, 2022, to March 30, 2022.
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 February 16, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the services at issue were a 
medical necessity for the enrollee. 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 ESRD provided on February 16, 2022.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for CPT 57120. We decided that the Plan does not have to pay for CPT 
57410 or 52787.  
 
You asked the Plan to pay for the services. You say that the enrollee was critically ill and required bedside 
management. The Plan says that these services do not require the use of an assistant surgeon. 
 
We decided that the Plan has to pay for CPT 57120.  
 
The Plan follows Medicare rules. Medicare rules say that for procedures with an assistant surgery indicator of 
2, the payment restriction for assistants at surgery does not apply and the assistant surgeon services will be 
paid. In this case, you billed assistant surgery services for CPT code 57120. The Medicare Fee Schedule 
Database contains a surgical indicator of 2 for this procedure.  
 
The file shows that CPT 57120 has a surgical status indicator of 2. The plan has denied this code stating "the 
procedure code is inconsistent with the modifier used." The modifier used was 80, for assistant surgeon. This 
modifier is valid, as an assistant surgeon is appropriate for this procedure. Based on this information, we 
decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has 
to pay for CPT 57120.  
 
We also decided that the Plan does not have to pay for CPT 57410 or 52787. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. CPT 52787 is an obsolete code, and not 
supported in this case. 
 
Additionally, The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery 
indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for 
Current Procedural Terminology (CPT) code 57410. The Medicare Fee Schedule Database contains a surgical 
indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not 
medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria 
for CPT 57410 have not been met. Therefore, we decided that the Plan does not have to pay for CPT 57410 or 
52787. 
 
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 or reduce the copayment and coinsurance for ophthalmic 
imaging and a ranibizumab injection provided on March 10, 2022. 
 
You asked the Plan to waive or reduce the copayment and coinsurance for the ophthalmic imaging and 
injection. You say that the cost share seems very high. The Plan denied your request. The Plan says the correct 
copayment and coinsurance were applied. 
 
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 
copayment per day for diagnostic tests. Your contract with the Plan also clearly says that you must pay a 20% coinsurance for each Part B drug. 
 
You have been asked to pay a $20 copayment for the ophthalmic imaging. The ophthalmic imaging falls within 
the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. You have also been 
asked to pay $307.20 for the injection, which is 20% of the allowed amount ($1,536.00 allowed amount x 20% 
coinsurance = $307.20). The injection falls within the Medicare Part B Prescription Drugs benefit category. 
The total for the services is $327.20. 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 or reduce the copayment and 
coinsurance for ophthalmic imaging and a ranibizumab injection provided on March 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 5, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 April 5, 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 an office visit provided on April 20, 2022, by an OON 
provider. 
 
You asked the Plan to pay for an office visit. You say to please find and review the included medical records to 
support the medical necessity of the services provided to the enrollee, in good faith. 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 an office visit provided on April 20, 2022, by an 
OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on March 14, 
2022. 
 
You asked the Plan to waive the copayment for lab services. You say that this was routine lab work. The Plan 
denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $30 
copayment for all other Medicare-covered lab services.  
 
You have been asked to pay $30 copayment for lab services. Lab services 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 laboratory services provided on March 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an onabotulinumtoxina injection provided 
on December 15, 2021. 
 
You asked the Plan to waive the coinsurance for an onabotulinumtoxina injection. You say that you would like 
this covered as it is medically necessary. The Plan denied your request. The Plan says this claim processed 
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 Medicare Part D prescription drugs.  
 
You have been asked to pay $974.40 for an onabotulinumtoxina injection. An onabotulinumtoxina injection 
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 coinsurance for Medicare Part B prescription 
drugs provided on December 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing care and debridement provided on 
February 22, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing care and debridement. You say that the service was 
medically necessary and requesting an authorization would have delayed care. The Plan denied your request. 
The Plan says no prior authorization was obtained. 
 
 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 did not pre-approve the 
subsequent nursing care and the debridement. We found no exception that would require the Plan to pay for the 
subsequent nursing care and the debridement. The records provided for review do not show that the services at 
issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the subsequent 
nursing care and debridement provided on February 22, 2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve four physical therapy visits. We also decided that the Plan does 
not have to pre-approve four physical therapy visits.  You asked the Plan to pre-approve therapy visits. You say that additional physical therapy is medically 
necessary. The Plan denied your request.  The Plan says that the enrollee has reached the expected level of 
improvement. 
 
We decided that the Plan has to pre-approve four physical therapy visits.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy visits. Our reviewer says that 
the coverage criteria has been met for four physical therapy visits. Our physician reviewer found that an 
additional four physical therapy visits are acceptable in terms of transitioning the enrollee to an independent 
home exercise program and concluding therapy and the unique skills of a professional therapist are required to 
provide this. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of four physical therapy visits have been met. Therefore, we decided that the Plan 
has to pre-approve four physical therapy visits.  
  
We also decided that the Plan does not have to pre-approve four physical therapy visits. 
 
Our reviewer says that four physical therapy visits are not necessary to restore or maintain function or to 
prevent deterioration of the enrollee's condition. Our physician reviewer found that the documentation does 
indicate that the enrollee has improved functionally in terms of standing and walking tolerance. 
 
Based on this information, we decided that Medicare rules for coverage of four physical therapy visits have not 
been met. Therefore, we decided that the Plan does not have to pre-approve four physical therapy visits.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Gelsyn-3 (J7328). 
 
You asked the Plan to pre-approve Gelsyn-3. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been 
met. 
 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 Gelsyn-3. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of drugs Euflexxa, Orthovisc and Durolane before they will approve the requested drug, 
Gelsyn-3. There is no indication that the enrollee has tried and failed the required drugs. Based on the medical 
records provided and the Medicare-approved major drug compendia there is no indication that the Plan's 
required drugs would likely be less effective and/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 Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Gelsyn-3 (J7328).