Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 30, 2021. 
 
You asked the Plan to pay for the office visit. You say that you were unaware that the Provider could not bill 
for this service. The Plan denied your request. The Plan says the chiropractic manipulative treatment has been 
covered and the office visit remains denied as a non-covered chiropractic service. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided on August 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 
You asked the Plan to pre-approve Feraheme. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Feraheme. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of Iron deficiency anemia secondary to blood loss (chronic). The 
documentation does not support that the enrollee has had a trial and failure of Infed (iron dextran) and Venofer 
(iron sucrose). The documentation does not support that Infed (iron dextran) and Venofer (iron sucrose) would 
likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Therefore, the 
requested drug does not meet step therapy criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monovisc injection. 
 
You asked the Plan to pre-approve Monovisc injection. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested injections are not a covered benefit. 
 
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 Monovisc injection. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a diagnosis of osteoarthritis of the knee. The record indicates that the 
enrollee has received viscosupplementation therapy in April 2022. The Food and Drug Administration has 
stated that the requested drug is indicated for the enrollee's condition. A repeat course of injection within six 
months of the completion of a course of injection is not medically necessary or reasonable as defined by 
Medicare rules. Therefore, the enrollee does not meet criteria for the requested services. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Monovisc injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Monovisc injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 26, 2021 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 May 26, 2021 by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture provided on November 5, 2021. 
 
You asked the Plan to pay for acupuncture. You say that acupuncture is a covered service. The Plan denied 
your request. The Plan says a licensed acupuncturist is a non-covered provider type and the provider is not 
supervised by any physician, physician assistant, nurse practitioner or a clinical nurse specialist. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.   We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, a licensed acupuncturist is a non-covered provider 
type and the provider is not supervised by any physician, physician assistant, nurse practitioner or a clinical 
nurse specialist. Therefore, we decided that the Plan does not have to pay for acupuncture provided on 
November 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth visit provided on January 4, 2022 to March 1, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for telehealth visit. You say that the services provided were medically necessary. 
The Plan denied your request. The Plan says OON virtual care is not a covered benefit. 
 
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 telehealth visit provided on January 4, 2022 to 
March 1, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus vaccine provided on December 23, 2021. 
 
You asked the Plan to pay for the tetanus vaccine. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says tetanus vaccines are not covered under your 
Medicare Part B benefit in this case. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the tetanus vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the tetanus 
vaccine. Therefore, we decided that the Plan does not have to pay for the tetanus vaccine provided on 
December 23, 2021.  
 
Benefits for the tetanus vaccine may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on December 
7, 2021. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you went it for a COVID-19 
test, not an office visit. You also say that the government should pay for COVID-19 testing with no copayment. 
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 $45 
copayment for an urgent care visit.  
 
The medical record shows you had an urgent care visit on December 7, 2021. You have been asked to pay a 
$45 copayment for an urgent care visit. An urgent care visit falls within the Urgently Needed 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 an urgent care visit provided on December 7, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
October 11, 2020, to October 16, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. 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 $370 
copayment per day for days 1-5 of Inpatient hospital care.  
 
 
  You have been asked to pay a $1,850 copayment for 5 days of inpatient hospital care ($370 x 5 = $1,850). 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 inpatient hospital stay provided from October 11, 2020, 
to October 16, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81295, 81298, 81432, and 81479) 
provided on August 12, 2021. 
 
You asked the Plan to pay for codes 81295, 81298, 81432, and 81479. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
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 81295 
and 81298 are column II codes to column I code 81432 with a modifier indicator of 0. These column II codes 
are therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. 
 
We also find that CPT codes 81432 and 81479 are not supported in the medical record. Specifically, the testing 
at issue in this case should be reported with CPT code 81479 only. Therefore, we decided that the Plan does not 
have to pay for the laboratory services (81295, 81298, 81432, and 81479) provided on August 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
chest provided on February 17, 2022. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you thought this would be covered at 
100%. 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 $250 
copayment for diagnostic radiology services, including CT scans.  
 
You have been asked to pay a $250 copayment for a CT scan. A CT scan 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 computed tomography (CT) scan of the chest provided on February 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for lumbar-sacral orthosis (L0650) provided 
on October 14, 2021. 
 
You asked the Plan to waive the coinsurance for the lumbar-sacral orthosis. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for Prosthetic Devices and Related Supplies.  
 
 
  You have been asked to pay a 20% coinsurance for the lumbar-sacral orthosis (allowed is $584.51 x 20% = 
$116.90). Lumbar-sacral orthosis falls within the Prosthetic Devices 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 lumbar-sacral orthosis (L0650) provided on October 14, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound care services provided on February 
9, 2022. 
 
You asked the Plan to waive the copayment for the wound care. You say that you never had a copayment for 
outpatient surgery before. 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 $250 
copayment for outpatient procedures and services.  
 
You have been asked to pay $221.14, which is less than the $250 copayment for the wound care. The wound 
care falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers 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 wound care 
services provided on February 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on January 3, 2022. 
 
You asked the Plan to waive the copayment for the office visit. 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 $0 
copayment for Physician/Practitioner services, including doctor's office visits.  
 
 
  You have been asked to pay a $27.92 copayment for the office visit. The record indicates that you have a dual 
plan, please have your provider submit the claim to Medicaid for payment as we do not have jurisdiction over 
them. 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 office visit provided on January 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Infusion pump refill kit (A4220) provided on November 
12, 2021. 
 
You asked the Plan to pay for code A4220. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that code A4220 has a status code of "P" under the Medicare Physicians Fee Schedule Database 
(MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into 
the payment for the services to which these codes are incident to. Therefore, we decided that the Plan does not 
have to pay for the Infusion pump refill kit (A4220) provided on November 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for radiation treatment provided from 
December 1, 2021, to December 23, 2021. 
 
You asked the Plan to waive the copayments for the radiation treatment. You say that the enrollee was under 
the impression that treatment would be fully covered based on his insurance card. The Plan denied your 
request. The Plan says the enrollee was 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $60 copayment for radiation therapy treatments.  
 
The enrollee has been asked to pay a $60 copayment for each of the 17 radiation treatments. The total for all 
treatments is $1,020 ($60 copayment x 17 treatments = $1,020). The radiation treatment falls within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that the 
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for radiation treatment provided from December 1, 2021, to December 
23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for therapy services provided on February 9, 
2022. 
 
You asked the Plan to waive the deductible for therapy services. You say that you should not have to pay this 
bill because it did not have anything to do with therapy for your finger after your surgery. 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. Your 
contract with the Plan says that there is $750 deductible which applies to outpatient therapy services.  
 
The record shows this claim was approved, and you have a cost sharing amount. The item or service you asked 
the Plan to waive the deductible for falls within the Outpatient Rehabilitation Services benefit category. The 
Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 deductible which 
applies to outpatient therapy services. This cost sharing is a contractual obligation that had not been met at the 
time therapy services was received on February 9, 2022. Therefore, we decided that the Plan does not have to 
waive the deductible for therapy services provided on February 9, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on December 9, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the laboratory services by a contract provider. The file does not show that the 
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on December 9, 2021.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Therapeutic activities (97530) provided on September 29, 
2021. 
 
You asked the Plan to pay for code 97530. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of an OTA shall not be billed as 
services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the 
qualifications of a therapist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of occupational therapy have not been met. Specifically, the billing provider is a nurse practitioner, 
and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for the Therapeutic activities (97530) 
provided on September 29, 2021.