Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on April 
18, 2022. 
 
You asked the Plan to waive the copayment for hospital care. You say that you are disputing the 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 $275 
copayment for days 1 through 6 per benefit period. This inpatient hospital stay lasted 1 day, resulting in a 
copayment amount of 275 copayment. 
 
You have been asked to pay $275 copayment for hospital care. This item/service falls within the days 1 through 
6 per benefit period 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 
care provided on April 18, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on January 1, 2022. 
 
You asked the Plan to pay for the emergency room services. You say that the services were not related to the 
enrollee's hospice diagnosis. The Plan denied your request. The Plan says the enrollees claim would be 
covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the providers 
responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the emergency room services provided on January 1, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 
You asked the Plan to pre-approve Ilumya. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 Ilumya. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, the enrollee has not tried and 
failed the required drugs. There is no documentation provided indicating that the plans 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 Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist visit provided on January 31, 
2022. 
 
You asked the Plan to waive the copayment for specialist visit. You say that you had no copayment with your 
previous plan so you want this copayment to be reconsidered 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, including doctors office visits. 
 
You have been asked to pay a $45 copayment for specialist visit. 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 specialist visit provided on January 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for therapeutic apheresis plasma provided from 
April 5, 2022, to April 26, 2022. 
 
You asked the Plan to waive the copayment for therapeutic apheresis plasma. You say that apheresis services 
are not surgical procedures, nor were they performed in a hospital. You say that although this office, where the 
services were rendered, is licensed by a hospital, the office is a doctor's office. 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 $100 
copayment for surgery at an outpatient hospital or ambulatory surgical center, including but not limited to a 
hospital or other facility charges and physician or surgical charges.  
 
You have been asked to pay a $100 copayment for each therapeutic apheresis plasma.  
 
Claim Number: Date of Service: Service: Copayment: 
063559793 April 5, 2022 36514  apheresis plasma $100 
063559793 April 12, 2022 36514  apheresis plasma $60 
063504958 April 15, 2022 36514  apheresis plasma $100 
063505040 April 19, 2022 36514  apheresis plasma $100 
063505008 April 22, 2022 36514  apheresis plasma $100 
063504973 April 26, 2022 36514  apheresis plasma $100 
  Total: $560 
 
 
This item/service falls within the surgery at an outpatient hospital or ambulatory surgical center, including but 
not limited to a hospital or other facility charges and physician or surgical charges benefit category. The record 
shows that these services were performed in an outpatient facility. 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 therapeutic apheresis plasma provided from April 5, 2022, to April 26, 2022.  
 
Your complaint about the potentially poor customer service you and your provider received from the Plan 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 3, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee 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 April 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve TheraSkin. 
 
You asked the Plan to pre-approve TheraSkin. 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 TheraSkin. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the wound is improving with the standard wound care administered from October 13, 2022 to 
October 21, 2022 once she completed your intravenous antibiotics on October 4, 2022. The review has 
determined that the requested items/services at issue in this case are not medically reasonable or 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 TheraSkin have not been met. Therefore, we decided that the Plan does not 
have to pre-approve TheraSkin.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OsteoCel Allograft. 
 
You asked the Plan to pre-approve OsteoCel Allograft. 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 OsteoCel Allograft. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested OsteoCel Allograft, in 
this case, is not medically reasonable or 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 OsteoCel Allograft have not been met. Therefore, we decided that the Plan does 
not have to pre-approve OsteoCel Allograft.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and drug test provided on May 16, 2022, by 
OON provider. 
 
You asked the Plan to pay for an office visit and drug test. You say that you inherited this patient when the old 
contract terminated. You say to please provide an authorization for this patient. 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 and drug test provided on May 16, 
2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for infusions provided from 
February 5, 2021, to July 1, 2022. 
 
You asked the Plan to waive the copayment and coinsurance for infusions. You say that you should not have to 
pay these extra charges for these services. The Plan's customer service did not inform you properly. 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 Physician/Practitioner services, including doctors office visits, and a 20% coinsurance for 
Medicare Part B prescription drugs. There is a $40 copayment per visit with the specialist, as well as a 20% 
coinsurance for Part B drugs, bringing your full total to $6,479.04.  
 
You have been asked to pay a to $6,479.04 cost for infusions. This item/service falls within the Medicare Part 
B prescription drugs and 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 and coinsurance for infusions provided from 
February 5, 2021, to July 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
May 19, 2021. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service May 19, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 home health physical therapy visits. 
 
You asked the Plan to pre-approve 8 home health physical therapy visits. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 8 home health physical therapy visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found based on the 
medical records provided there is no documentation that the eight additional skilled therapy visits are required 
to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to 
establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent 
deterioration. Provided records do not document any acute or unstable medical conditions or injuries which 
would necessitate any further skilled therapy visits beyond what have already been approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 8 home health physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 8 home health physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on 
April 21, 2022. 
 
You asked the Plan to waive the copayment for these services. You say that the enrollee should not have to pay 
because he has a detached retina. The Plan denied your request. The Plan says the copayment was 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 $225 
copayment for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital 
facility.  
 Review of the file shows that the enrollee had cataract surgery on April 21, 2022. The enrollee has been asked 
to pay a $225 copayment for these services. This item/service falls within the outpatient surgery and/or services 
at an ambulatory surgical center or outpatient hospital facility benefit category. This means that the enrollee has 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay when they enrolled in the Plan. Therefore, we decided that the Plan does 
not have to waive the copayment for the outpatient surgical services rendered on April 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64999-50 provided on February 25, 2022. 
 
You asked the Plan to pay for procedure code 64999-50. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says they were unable to make a determination 
within the allotted time frame. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Based on this information, we find that Medicare criteria for the 
billing of code 64999 with modifier 50 is not payable. Procedure code 64999 has a bilateral surgical indicator 
of 0. It is inappropriate to bill modifier 50 with these codes. Therefore, we decided that the Plan does not 
have to pay for procedure code 64999-50 provided on February 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 30, 2021, billed with 
codes 81206, 81210, 81235, and 81272. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 30, 2021, billed with codes 81206, 81210, 81235, and 81272.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated abutments (D6056) and placement of 
implant body (D6010) for tooth #4, #7, #11, and #14. 
 
You asked the Plan to pre-approve the dental services. You say that you need the dental procedures completed. 
The Plan denied your request. The Plan says the denial of authorization for these services is correct, because 
prefabricated abutments and placement of implant body are not covered by the Plan. 
 
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. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
prefabricated abutments (D6056) and placement of implant body (D6010) for tooth #4, #7, #11, and #14.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 3, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that You wanted to use a different provider. 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 office visit provided on June 3, 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 procedure code 99072 billed for date of service July 21, 
2021. 
 
You asked the Plan to pay for procedure code 99072. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 99072 is considered bundled 
and not separately payable. 
 
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 code 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99072 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99072 billed for date of service July 21, 2021.