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

 
We decided that the Plan does not have to reduce the cost share for the arthrocentesis and Part B drug provided 
by a network specialist on July 21, 2021. 
 
You asked the Plan to reduce the cost share for the arthrocentesis and the Part B drug. You say that you should 
only be charged $172.88 because your drug cost deductible is $240. The Plan denied your request. The Plan 
says you have been asked to pay 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 $40 
copayment for services obtained from an in-network specialist, or under certain circumstances, treatment by a 
nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office 
and 20% coinsurance each in-network Medicare-covered drug.  
 
You have been asked to pay a $40 copayment for the arthrocentesis and $401.76 which is 20% of the allowed 
amount for the Part B drug. The allowed amount is $2,008.80. ($2,008.80 x 20% = $401.76). The 
arthrocentesis falls within the Physician/Practitioner Services, Including Doctors Office Visits benefit 
category. The Part B drug falls within the Medicare Part B Prescription Drugs benefit category. The record 
shows the Part B drug does not apply to the Part D drug deductible. 
 
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 cost share for the arthrocentesis and Part B drug provided by a network 
specialist on July 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
December 7, 2021. 
 
You asked the Plan to waive the copayment for the emergency room 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 $90 
copayment for Emergency care.  
 
 
  You have been asked to pay a $90 copayment for an emergency room visit. 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 emergency room visit provided on December 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fluid flow or fluid gf, 1 cc (Q4206) provided on  
November 5, 2021. 
 
You asked the Plan to pay for Fluid flow or fluid gf, 1 cc. The Plan denied your request. The Plan says the 
clinical value and effectiveness of Fluid Flow injections in the setting of osteoarthritis has not been 
demonstrated in the peer-reviewed literature. The medical effectiveness has not been verified by scientifically 
controlled studies. 
 
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 pay for Fluid flow or fluid gf, 1 cc. Our reviewer says that the requested Fluid flow or fluid gf is not considered medically reasonable and necessary in this case. 
Our physician reviewer found this procedure does not have sufficient evidence to support its use for shoulder 
pain. Therefore, the injection was 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 Fluid flow or fluid gf, 1 cc have not been met. Therefore, we decided that the 
Plan does not have to pay for fluid flow or fluid gf, 1 cc (Q4206) provided on November 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99214) provided on 
November 15, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service 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 $30 
copayment for a specialist office visit.  
 
You have been asked to pay a $30 copayment for the specialist office visit provided as you had not previously 
met your maximum out of pocket amount for the calendar year at the time of service.  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 office visit (99214) provided on  
November 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuromonitoring services (51785, 95861) provided 
September 21, 2021. 
 
You asked the Plan to pay for the neuromonitoring services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 CPT codes 51785, & 95861 are not supported in the medical record. Specifically, the technical 
report did not include documentation of needle electromyography studies (EMG) of anal or urethral sphincter. 
The technical report did not include documentation of a needle electromyography for 2 extremities with or 
without related paraspinal areas. Based on this information, we decided that Medicare rules for coverage of the 
neuromonitoring services have not been met. Therefore, we decided that the Plan does not have to pay for 
neuromonitoring services (51785, 95861) provided September 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for cataract surgery provided on September 
22, 2021, and October 13, 2021. 
 
You asked the Plan to waive the copayments for cataract surgery. You say that you were unaware that you 
would be required to pay a copayment for eye surgery. You also say that you are being charged a $350 
copayment for each cataract surgery when Medicare told you it was covered with no mention of a 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 $350 
copayment for each in-network outpatient surgery at an outpatient hospital.  
 
 The record shows the claims have been processed correctly. You have been asked to pay a $350 copayment for 
each cataract surgery on September 22, 2021, and October 13, 2021. Cataract surgery 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 copayments for cataract surgery provided 
on September 22, 2021, and October 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (K0862, 
E2363, K0108, E1028, E2377, E2313, E1007, E2300, E2621, E2311, E0955, E1012, E2608). 
 
You asked the Plan to pre-approve the group 3 power wheelchair and accessories. You say that the power chair 
is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
 
 
 The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or 
congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group 3 
power wheelchair and accessories (K0862, E2363, K0108, E1028, E2377, E2313, E1007, E2300, E2621, 
E2311, E0955, E1012, E2608).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the continuous positive airway pressure 
(CPAP) supplies provided by a network provider on September 9, 2021. 
 
You asked the Plan to waive the coinsurance for the CPAP supplies. You say that you are appealing this claim 
because you were not given the correct supplies. The Plan denied your request. The Plan says you have been 
asked to pay 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 20% 
coinsurance for durable medical equipment and related supplies.  
 
 You have been asked to pay $43.58 which is 20% of the allowed amount for the CPAP supplies. The allowed 
amount is $217.90. ($217.90 x 20% = $43.58). The CPAP supplies fall within the Durable medical equipment 
(DME) and related supplies benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the 
continuous positive airway pressure (CPAP) supplies provided by a network provider on September 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a multi-positional patient support system, with integrated lift, 
patient accessible controls (E0636) provided on September 13, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a multi-positional patient support system, with integrated lift, patient accessible 
controls. You say that the doctor's office provided you with brochures, which were available upon request, for 
2 equipment providers, and stated to select and schedule necessary rentals. The Plan denied your request. The 
Plan says the member did not obtain authorization for the durable medical equipment, and the provider is out-
of-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 a multi-positional patient support system, with 
integrated lift, patient accessible controls (E0636) provided on September 13, 2021, by an out-of-network 
(OON) provider.  
 
Your complaint about potentially not being informed of proper procedure 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 waive the copayments for the diagnostic hearing tests and the 
specialist office visits provided on October 20, 2021, and October 26, 2021. 
 
You asked the Plan to waive the copayments for the diagnostic hearing tests and the specialist office visits. You 
say that the situation was an emergency, and you should not be responsible for the diagnostic testing. The Plan 
denied your request. The Plan says documentation shows that the services were provided. Therefore, the proper 
copayments were applied for each date of service. 
  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 $50 
copayment for Medicare-covered diagnostic hearing evaluation and each Medicare-covered specialist office 
visit. On October 20, 2021, you were charged a $50 copayment for the diagnostic hearing test and a $50 
copayment for the specialist office visit. A total of $100 ($50 copayment + $50 copayment) was charged as the 
copayment. On October 26, 2021, the total amount allowed was the diagnostic hearing test was $41.67 which is 
less than the copayment amount of $50. Therefore, only $41.67 was charged as the copayment for the 
diagnostic hearing test and the $50 copayment for the specialist office visit. The total copayment amount for 
October 26, 2021, was $91.67 ($41.67 copayment + $50 copayment). For both dates of service, the total 
copayment amount was $191.67 ($100 total copayment + $91.67 total copayment). 
 
You have been asked to pay a $191.67 copayment for the diagnostic hearing tests and the specialist office 
visits. The diagnostic hearing test falls within the Hearing services benefit category. The specialist office visits 
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 copayments for the diagnostic hearing tests and the specialist office visits provided 
on October 20, 2021, and October 26, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on October 
26, 2021. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that you were only in the room 
for a couple of minutes and no treatment was provided. The Plan denied your request. The Plan says 
documentation shows the enrollee received the services. Therefore, the proper copayment was 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 $50 
copayment for each Medicare-covered urgent care facility visit Cost-sharing is not waived if you are admitted 
to the hospital.  
 
  You have been asked to pay a $50 copayment for the urgent care visit. The 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 October 26, 2021.  
 
Your complaint about your experience with this provider 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 waive the copayment for a specialist office visit provided on October 
4, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you did not have surgery 
during the date of service so you should not have a copayment. The Plan denied your request. The Plan says 
documentation shows the enrollee was seen for an office visit and not surgery. Therefore, the proper 
copayment was applied for an office visit. 
 
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 $30 
copayment per specialist visit.  
 
  You have been asked to pay a $30 copayment for the specialist office visit. The specialist office visit 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 a specialist office visit provided on October 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on September 22, 2021. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. You say that your wife called 
911 after you became ill and when the paramedics arrived, they check you and you felt better and you were not 
transported. The Plan denied your request. The Plan says the transport of a Medicare beneficiary must occur for 
an ambulance transport to be payable under the Medicare Program. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 22, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
(A0998) provided on September 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram provided on October 
20, 2021. 
 
You asked the Plan to waive the copayment for the electrocardiogram. 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 $50 
copayment for Outpatient hospital services, specifically diagnostic procedures and tests. 
 
 
  You have been asked to pay a $50 copayment for the electrocardiogram. Electrocardiograms fall 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 an 
electrocardiogram provided on October 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on November 9, 2021, by 
an OON provider. 
 
You asked the Plan to pay for the home health services. You say that this service did not require prior 
authorization. The Plan denied your request. The Plan says the services were provided out-of-network and were 
not approved in advance 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the home health services provided on November 9, 
2021, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an Injection of Anesthetic Agent (Nerve Block) provided on 
August 4, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Injection of Anesthetic Agent (Nerve Block). You say that you would like to 
request reconsideration for payment. The Plan denied your request. The Plan says the non-urgent services are 
not authorized because provider is a non-network provider with the members health plan, and no referring 
provider is listed on the claim. 
 
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 Injection of Anesthetic Agent (Nerve Block) 
provided on August 4, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70470 billed for date of service June 30, 
2021. 
 You asked the Plan to pay for procedure code 70470. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70470 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 70470 
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 70470 billed for date of service June 30, 2021.