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

 
We decided that the Plan does not have to pay for procedure code S9366 billed for date of service June 23, 
2022 to June 29, 2022. 
 
You asked the Plan to pay for procedure code S9366. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 S9366 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9366 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9366 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9366 billed for date of service June 23, 2022 to June 29, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for fundus photography, and an eye refraction. We decided that the Plan 
does not have to waive the copayment for an eye examination.  
 
You asked the Plan to pay for an eye examination (99214), an eye refraction (92015), and fundus photography 
(92250) provided on July 27, 2022. You say that the services should be covered. The Plan says that this cost 
sharing was charged correctly. 
 
We decided that the Plan has to pay for fundus photography, and an eye refraction.  
 
The Plan follows Medicare rules. Medicare rules say that Plans must disclose cost sharing in clear and accurate 
terms.  
 
We find that the contract does not state in clear and accurate terms how a routine vision service would be 
covered when provided along with a medical eye exam. Additionally, the $40 copayment for a medical eye 
exam is defined as applying to physician services related to a disease or condition of the eye. Both the 
examination and the fundus photography are part of this same diagnosis/treatment. As such, a separate 
copayment for this imaging is not supported by the contract language. Therefore, we decided that the Plan has 
to pay for fundus photography, and an eye refraction.  
 
We also decided that the Plan does not have to waive the copayment for an eye examination. 
 
The Plan follows Medicare rules. 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 a medical eye exam. 
 
The records show that this examination was follow-up for a medical eye condition choroidal nevus. This 
means that the exam falls into the above noted 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 eye examination. 
 
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 pay for the self-administered drugs provided in an outpatient setting 
and to waive the copayment for the emergency room visit provided on June 11, 2022. 
 
You asked the Plan to pay for the self-administered drugs and waive the copayment for the emergency room 
visit. You say that you did not ask for the mediation that was given to you. The Plan denied your request. The 
Plan says the drug you received is considered self-administered. The Plan says self-administered drugs are 
covered under a Medicare Part D prescription drug plan. The Plan also says the drug you received is not 
covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The rules also say that a plan must disclose to its enrollees in clear, accurate terms all cost 
sharing information (such as copayments, deductibles and coinsurance). 
 
The self-administered drugs you received are not among the types which are covered by Medicare Part B. 
Additionally, you have been asked to pay an $90 copayment for the emergency service. This service falls 
within the Emergency Care 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 pay for the self-administered drugs 
provided in an outpatient setting, nor waive the copayment for the emergency room visit provided on June 11, 
2022.  
 
Benefits for the self-administered drugs 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: Favorable

 
We decided that the Plan has to pay for the manual therapy (97140) provided on June 22, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the supplemental benefit for this service 
has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has stated that the supplemental benefit for this service has 
been exhausted. However, the Plan has not provided documentation to prove that this benefit has been 
exhausted. Therefore, the Plan has not substantiated their denial and we must find in your favor. Therefore, we 
decided that the Plan has to pay for the manual therapy (97140) provided on June 22, 2022.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF 
admission. 
 
The Plan must follow Medicare rules. The rules say that an IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found that the complexity of the enrollees nursing, medical and rehabilitation needs 
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollees medical problems are stable. She does not have complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve epidural steroid injection to the spine of the lower back. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the guideline requirements were not met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has chronic low back pain. The enrollee takes Mobic, Norco, Tramadol, and Baclofen 
for the pain. The enrollee has tried physical therapy, but was unable to tolerate it. The criteria has been met, 
and the request is medically reasonable and 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 the services have been met. Therefore, we decided that the Plan has to pre-
approve epidural steroid injection to the spine of the lower back.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for shoulder orthosis provided on May 19, 
2022. 
 
You asked the Plan to waive the coinsurance for shoulder orthosis. You say that you disagree with the 
coinsurance. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Durable medical equipment (DME) and related supplies.  
 
You have been asked to pay 20% coinsurance for shoulder orthosis. The total allowed amount for the shoulder 
orthosis is $64.49. The amount you are being asked to pay is $64.49 ($64.49 x 20% = $12.90). 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 shoulder orthosis provided on May 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on May 17, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for wound care. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollees network primary care provider (PCP) or plan must give the enrollee 
approval in advance before they can use providers not in the plan's network. This is called giving you a 
"referral." 
 
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 wound care provided on May 17, 2022, by an out-
of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a determination of refractive state (92015) provided on July 
18, 2022. 
 
  You asked the Plan to pay for a determination of refractive state (92015). You say that this was a regular eye 
exam as far as you are concerned, as you have had them there before without any problem. The Plan denied 
your request. The Plan says eye refractions are only covered by your plan if performed by a participating eye 
quest provider and performed as a routine screening. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers eye refractions when provided during a routine exam. 
 
We looked at the file and the Plan's rules. The rules say that eye refractions are covered when provided during a 
routine exam. The record shows that the charges were billed with a medical diagnosis for an eye refraction. 
Based on this information, we decided that the Plan's rules for coverage of a determination of refractive state 
(92015) have not been met. Therefore, we decided that the Plan does not have to pay for a determination of 
refractive state (92015) provided on July 18, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for outpatient rehabilitation service provided 
on July 11, 2022. 
 
You asked the Plan to reduce the copayment for physical therapy. You say that you are looking to reduce your 
physical therapy copayments. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $40 
copayment for Medicare-covered therapy visit.  
 
You have been asked to pay $40 copayment for physical therapy. This item/service falls within the Medicare-
covered therapy visit benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for outpatient 
rehabilitation service provided on July 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for dental services on June 24, 2022. 
 
You asked the Plan to waive the copayment for dental services. You say that you would like to appeal the cost 
share. 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 for 
dental services.  
 
You have been asked to pay for dental services. This item/service falls within the dental 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 dental services on June 24, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency services provided from July 5, 
2022, to July 13, 2022. 
 
You asked the Plan to waive the copayment for emergency services. You say that you are asking Freedom 
Health to waive the cost share applied to claim for emergency services that you received in Mexico. 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 $500 
copayment per visit for emergency service, urgent service, and emergency transportation outside the U.S. 
 
You have been asked to pay a $500 copayment per visit for emergency services. The total amount you are 
being asked to pay is $1000 ($500 x 2 visits = $1000). 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 
emergency services provided from July 5, 2022, to July 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthopedic services provided from May 20, 2022, to June 8, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the orthopedic services. You say that you believe the situation was an 
emergency, and your son recommended this provider. The Plan denied your request. The Plan says a 
referral/authorization was not obtained prior to services being rendered. 
 
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 orthopedic services provided from May 20, 2022, 
to June 8, 2022, by an out-of-network (OON) provider.
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 June 
16, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you are just finding out 
that you have and outstanding bill. 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 $20 
copayment for Physician/Practitioner services/Medicare covered specialist visit.  
 
You have been asked to pay a $20 copayment for a specialist office visit. This item/service falls within the 
Physician/Practitioner services/specialist visit 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 June 16, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound (76775) provided on June 28, 2022. 
 
You asked the Plan to pay for procedure code 76775. 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. 
 
We looked at the file and Medicare rules. Review of the file shows the claim was billed with an outpatient 
place of service code of 22. The file shows that the enrollee was registered as an inpatient for the date of 
service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ultrasound 
(76775) provided on June 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for foot orthotics provided on November 17, 
2021. 
 
You asked the Plan to waive the coinsurance for foot orthotics. You say that you already paid the provider, 
there shouldn't be a coinsurance. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment (DME) and related supplies.  
 
You have been asked to pay a 20% coinsurance for foot orthotics. This item/service falls 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 foot orthotics provided on November 17, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on July 6, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for physical therapy. You say that this should be covered. The Plan denied your 
request. The Plan says there was no preauthorization by a primary care provider (this is different than a 
referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, the 
decision is upheld. 
 
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 physical therapy provided on July 6, 2022, by an 
out-of-network (OON) provider.