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

 
We decided that the Plan does not have to waive the coinsurance for a collagenase injection provided on March 
15, 2022. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you feel you were billed twice for 
one injection. The Plan denied your request. The Plan says the correct coinsurance 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 20% 
coinsurance for Part B drugs. 
 
Drug Allowed Amount 20% Coinsurance 
Collagenase (1) $3,283.03 $656.61 
Collagenase (2) $1,811.33 $362.27 
Total:  $1,018.88 
 
 
 You have been asked to pay a total of $1,018.88, which is 20% of the allowed amount for the injection. The 
injection falls within the Medicare Part B Prescription Drugs benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for a collagenase injection provided on March 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) provided on 
February 14, 2022. 
 
You asked the Plan to waive the copayment for the EKG. You say that the service should be covered with the 
office visit. 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 $100 
copayment for diagnostic procedures and tests.  
 
You have been asked to pay $12.87, which is less than the $100 copayment for the EKG. The EKG 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 an electrocardiogram (EKG) provided on February 14, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy on February 15, 2022. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for physical therapy at an outpatient hospital. Covered services include physical therapy, 
occupational therapy, and speech language therapy. Outpatient rehabilitation services are provided in various 
outpatient settings, such as hospital outpatient departments, independent therapist offices, and Comprehensive 
Outpatient Rehabilitation Facilities (CORFs). 
 
You have been asked to pay a $40 copayment for physical therapy. Physical therapy falls within the Outpatient 
rehabilitation 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 physical 
therapy on February 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for a nerve block injection 
provided on November 30, 2021, and a denosumab injection provided on January 11, 2022. 
 
You asked the Plan to waive the copayment and coinsurance for the injections. You say that you were not made 
aware of any costs at the times of service. The Plan denied your request. The Plan says the correct copayment 
and coinsurance were applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment per day for outpatient procedures and services. 
 
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for Part B non-
chemotherapy drugs. You have been asked to pay a $350 copayment for the nerve block injection. The nerve block injection falls 
within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers benefit category. You have also been asked to pay $254.46 for the denosumab injection, 
which is 20% of the allowed amount ($1,272.30 allowed amount x 20% coinsurance = $254.46). The 
denosumab injection falls within the Medicare Part B Prescription Drugs benefit category. The total for both 
visits is $604.46. 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 a nerve block 
injection provided on November 30, 2021, and a denosumab injection provided on January 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services provided to the enrollee on February 14, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99291 (1 Unit) remains not supported. 
 
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, the CPT Code Manual definition of code 99291 is "Critical care, evaluation and management of 
the critically ill or critically injured patient; first 30-74 minutes." 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, there was no documentation 
showing the time spent providing the critical care services. This documentation is necessary as CPT 99291 is a 
time-based code. Based on this information, we decided that Medicare rules for coverage of the services have 
not been met. Therefore, we decided that the Plan does not have to pay for critical care services provided to the 
enrollee on February 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a stress test provided on January 26, 2022. 
 
You asked the Plan to waive the copayment for a stress test. You say that you were unaware there was a 
copayment for this test and should not have to pay for something you were unaware of. The Plan denied your 
request. The Plan says the copayment applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copayment for outpatient diagnostic tests.  
 
You have been asked to pay a $150 copayment for a stress test. a stress test falls within the Outpatient 
Diagnostic Tests - Advanced Imaging 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 a stress test provided on January 26, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a myocardial perfusion imaging (SPECT) 
test provided on November 15, 2021. 
 
You asked the Plan to waive the copayment for the SPECT test. You say that stress tests have a $0 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 $0 
copayment for nuclear medicine at a freestanding radiological facility or outpatient hospital. 
 
Your contract with the Plan also clearly says that you must pay a $40 copayment for each specialist office visit. 
 The file shows that the procedure was performed in a specialty clinic, not a freestanding radiological facility or 
outpatient hospital. Therefore, you have been asked to pay a $40 copayment for the SPECT test. The SPECT 
test in a specialty clinic falls within the Physician/Practitioner Services, Including Doctor's 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 myocardial perfusion imaging (SPECT) test 
provided on November 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service January 31, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 76705 is bundled into payment for code 93976. 
 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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service January 31, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for prosthetic device repair provided on March 
14, 2022. 
 
You asked the Plan to waive the deductible for the prosthetic repair. You say that you were informed afterward 
that the provider was not in-network. The Plan denied your request. The Plan says the correct amount was 
applied to your deductible. 
 
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 $1,000 deductible which applies to certain items and services.  
 
The prosthetic repair falls within the Prosthetic Devices and Related Supplies benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is $1,000 deductible which applies to 
certain items and services. This cost sharing is a contractual obligation that had not been met at the time the 
prosthetic repair was provided on March 14, 2022. Therefore, we decided that the Plan does not have to waive 
the deductible for prosthetic device repair provided on March 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthopedic services provided from January 14, 2020, to 
May 20, 2020. 
 
You asked the Plan to pay for the orthopedic services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the provider has opted out of the Medicare 
program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
orthopedic services provided from January 14, 2020, to May 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on January 13, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you thought this was a routine test 
that happened during your physical, and that you should not need to pay this copayment. The Plan denied your 
request. The Plan says the copayment applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 
copayment for other outpatient diagnostic tests.  
 
You have been asked to pay the allowed amount of $101.16 which is less than the $125 copayment for an 
ultrasound. An ultrasound falls within the Other Outpatient Diagnostic Tests  Medicare Covered 
Radiological Diagnostic 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 ultrasound provided on January 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Erleada tablets. 
 
You asked the Plan to pre-approve Erleada tablets. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Erleada tablets are not covered under the enrollee's 
Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Erleada tablets.  
 
Benefits for Erleada tablets 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ForeseeHome diagnostic test for the enrollee. 
 
You asked the Plan to pre-approve the test. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested service is not considered medically necessary as it is not the standard of 
care for non-exudative age-related macular degeneration which is actively being treated and monitored with 
examination and imaging. 
 
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 the test. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the record indicates that the enrollee has non-exudative age related macular degeneration. The record 
submitted does not contain medical records supportive of the requested service. The provided records are 
insufficient to determine the medical necessity and reasonableness, as defined by Medicare rules, of the 
requested service for the enrollee's specific clinical condition. The elements of the coverage rules are not 
satisfied.  
 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 test have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the ForeseeHome diagnostic test for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics (L3100) provided on April 14, 2022. 
 
You asked the Plan to pay for foot orthotics. You say that the item at issue was a medical necessity for your 
recovery. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics (L3100) provided on 
April 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hyperbaric oxygen therapy provided on June 9, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that the enrollee presented the wrong insurance card. The 
Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior 
authorization. 
 
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 hyperbaric oxygen therapy provided on June 9, 
2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Foresee Home system for the enrollee. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not the standard of care for treatment or monitoring. 
 
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 the system. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not support that the ForeseeHome monitoring system is medically 
reasonable and necessary for the enrollee's condition of nonexudative macular degeneration in this case. 
 
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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Foresee Home system for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ophthalmic diagnostic imaging provided on 
April 14, 2022. 
 
You asked the Plan to waive the copayment for the ophthalmic imaging. You say that  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 $150 
copayment for diagnostic procedures and tests.  
 
You have been asked to pay $35.68, which is less than the $150 copayment for the ophthalmic imaging. The 
ophthalmic imaging 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 ophthalmic diagnostic imaging provided on 
April 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64416 billed for date of service November 2, 
2021. 
 
You asked the Plan to pay for procedure code 64416. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 64416 is bundled into payment for code 01630. 
 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 64416 
is a column II code to column I code 01630. 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 64416 billed for date of service November 2, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiation treatment visits on December 30, 
2019, and December 31, 2019. 
 
You asked the Plan to waive the copayment for radiation treatment visits. You say that you should not have to 
pay this copayment, as you paid your copayments at the time of service back in 2019 and should not have any 
additional charges at this time. The Plan denied your request. The Plan says the copayment applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $60 
copayment for therapeutic radiology.  
 
You have been asked to pay a $120 copayment ($60 x 2 visits = $120) for radiation treatment visits. Radiation 
treatment visits falls within the Therapeutic Radiology 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 radiation treatment visits on December 30, 2019, and December 31, 2019.  
 Your complaint about how long the bill has been delayed for 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.