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

 
We decided that the Plan does not have to waive the $30 copayment for a specialist telemedicine visit on 
March 14, 2022. 
 
You asked the Plan to waive the $30 copayment for a specialist telemedicine visit. You say that you should not 
have to pay for this because the telemedicine visit reception was not what you expected. The Plan denied your 
request. The Plan says you are responsible to pay a $30 copayment for certain telehealth services, including 
specialist services. 
 
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 Physician/Practitioner Services, Including Doctors Office Visits.  
 
You have been asked to pay a $30 copayment for a specialist telemedicine visit. A specialist telemedicine visit 
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 $30 copayment for a specialist telemedicine visit on March 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on January 20, 2022. 
 You asked the Plan to pay for the testing services. You say that the testing was necessary for the management 
of the enrollee's advanced cancer. The Plan denied your request. The Plan says the panel is statutorily excluded. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The testing at issue includes the FANCC gene. Panels that include 
this gene are not a Medicare benefit. Based on this information, we decided that Medicare rules for coverage of 
the testing have not been met. Therefore, we decided that the Plan does not have to pay for the gene panel 
testing provided on January 20, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on February 19, 2022. 
 
You asked the Plan to pay for the ambulance service. You say that you were advised that you pay the first $100 
for ambulance services. You say that an ambulance was called when you fainted at church. You say that a plan 
representative confirmed you had received ambulance services. You also say that while you will pay this bill, 
you expect to be reimbursed $50. The Plan denied your request. The Plan says since there was no transport 
provided, there is no payable service. The Plan also says that you signed a refusal form for transportation after 
being advised you would need to go to the hospital for further evaluation. 
 
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 February 19, 2022. 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 the ambulance response and treatment, no 
transport, (A0998) provided on February 19, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for nuclear medicine provided on March 15, 
2022. 
 
You asked the Plan to waive the copayment for nuclear medicine. You say that you thought you would only 
have a $35 copayment. The Plan denied your request. The Plan says the copayment applied 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 $325 
copayment for nuclear medicine services in an outpatient hospital facility.  
 
You have been asked to pay $325 copayment for nuclear medicine. Nuclear medicine 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 nuclear medicine provided on March 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 5, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. 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 March 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $1200 copayment for an inpatient hospital stay from 
February 28, 2022, to March 7, 2022. 
 
You asked the Plan to waive the $1200 copayment for the inpatient hospital stay. You say that you think most 
of this bill should be covered. The Plan denied your request. The Plan says for in-network inpatient hospital 
care, you are responsible to pay a $240 copayment per day, for days 1 to 5. 
 
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 $240 
copayment per day for Inpatient Hospital Care.  
 
 
 You have been asked to pay a $1200 ($240x5days=$1200) copayment per day for an inpatient hospital stay. An 
inpatient hospital stay falls within the Inpatient Hospital 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 waive the $1200 copayment for an inpatient hospital stay from February 28, 2022, to March 7, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic colonoscopy provided on April 
1, 2022. 
 
You asked the Plan to waive the copayment for colonoscopy. You say that you were made to take the 
Cologuard test which came back positive and made the colonoscopy become diagnostic. Since you had no 
choice to take it the test should be covered. The Plan denied your request. The Plan says the copayment applied 
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 $325 
copayment for each Medicare covered outpatient hospital facility visit.  
You have been asked to pay $325 copayment for colonoscopy. Diagnostic colonoscopys fall within the 
Outpatient Surgery Including Services Performed 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 diagnostic colonoscopy 
provided on April 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the post tibial neurostimulation treatments 
provided in specialist's office on April 7, 2021, to February 11, 2022. 
 
You asked the Plan to waive the copayments for post tibial neurostimulation treatments. You say that you have 
had neurostimulation treatments since 2016 and have not been assessed a copayment. The Plan denied your 
request. The Plan says you are responsible to pay a $25 copayment for physician specialist services. 
 
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 $75 
cost share for Physician/Practitioner Services, Including Doctor's Office Visits.  
 
You have been asked to pay a $125 cost share for post tibial neurostimulation treatments ($25x5=$125). Post 
tibial neurostimulation treatments 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 copayments for the post tibial neurostimulation 
treatments provided in specialist's office on April 7, 2021, to February 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have waive the $84.58 coinsurance for optometry services on January 11, 
2022. 
 
You asked the Plan waive the $84.58 coinsurance for optometry services. You say that you should not be 
responsible to pay this because you were not a new patient and did not ask to see a doctor. The Plan denied 
your request. The Plan says the coinsurance has been applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 40% 
coinsurance for out-of-network Physician/Practitioner Services, Including Doctor's Office Visits.  
 
You have been asked to pay a 40% coinsurance for optometry services. Optometry services fall 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 
waive the $84.58 coinsurance for optometry services on January 11, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER services provided on April 10, 2022. 
 
You asked the Plan to waive the copayment for ER services. You say that you only saw a nurse so this should 
be covered. The Plan denied your request. The Plan says the copayment applied 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 $90 
copayment per emergency room visit.  
 
 
 
 You have been asked to pay $90 copayment for ER services. ER services fall 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 waive the copayment for ER services provided on April 
10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 9, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for triamcinolone injection provided on February 22, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for triamcinolone injection. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says the services were provided out-of-network and were not 
approved in advanced. 
 
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 triamcinolone injection at issue in this appeal. The Plan did not pre-
approve the triamcinolone injection at issue. We found no exception that would require the Plan to pay for the 
triamcinolone injection. Therefore, we decided that the Plan does not have to pay for triamcinolone injection 
provided on February 22, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an outpatient visit and debridement to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an outpatient visit and debridement. You say that you have seen this 
physician for a few years and would like to continue seeing them. The Plan denied your request. The Plan says 
the services have been requested out-of-network and there are in-network providers available. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an outpatient visit and debridement to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Freestyle Kit Lite and a Freestyle Test Lite provided from 
June 1, 2022, to June 4, 2022. 
 
You asked the Plan to pay for a Freestyle Kit Lite and a Freestyle Test Lite. You say that you are appealing 
with supporting documents. The Plan denied your request. The Plan says they require use of preferred brands 
Accu-Chek or OneTouch, but the enrollee purchased Freestyle, therefore its non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a plan must ensure that:  
-Its contracts with DME suppliers ensure that enrollee have access to all DME brands, items, and supplies of 
preferred manufacturers. 
-Enrollees have access to all medically-necessary DME brands, items, and supplies of non-preferred 
manufacturers. 
-At the enrollees request, it provides for an appropriate transition process for new enrollees.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of freestyle Kit lite and freestyle test Lite have not been met. Therefore, we decided that the Plan does 
not have to pay for a Freestyle Kit Lite and a Freestyle Test Lite provided from June 1, 2022, to June 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical fluoride varnish (D1206), the adjunctive pre-
diagnostic test (D0431), localized delivery of antimicrobial agents (D4381), drugs or medicaments (D9630), 
desensitizing medicaments (D9910), periodontal scaling and root planing-four or more teeth per quadrant 
(D4341), the unlisted adjunctive procedure, by report (D9999), and the gingival irrigation per quadrant 
(D4921) provided from March 29, 2022, through April 1, 2022. 
 
You asked the Plan to pay for these items/services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says these items/services are not a covered benefit under 
your contractual policy. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the items/services provided are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
topical fluoride varnish (D1206), the adjunctive pre-diagnostic test (D0431), localized delivery of antimicrobial 
agents (D4381), drugs or medicaments (D9630), desensitizing medicaments (D9910), periodontal scaling and 
root planing-four or more teeth per quadrant (D4341), the unlisted adjunctive procedure, by report (D9999), 
and the gingival irrigation per quadrant (D4921) provided from March 29, 2022, through April 1, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on March 7, 
2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that since you were admitted into 
the hospital this should be covered. The Plan denied your request. The Plan says the copayment applied 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 $150 
copayment for Medicare covered ground ambulance services (per one-way trip).  
 
You have been asked to pay $150 copayment for ambulance transport. Ambulance transport falls within the 
Ambulance 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 ambulance transport 
provided on March 7, 2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve 10 physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that additional physical therapy is medically 
necessary. The Plan denied your request. The Plan says that the enrollee is stable and can perform a home 
exercise program. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy visits. Our reviewer says that 
the coverage criteria has been met. Our physician reviewer found that the clinical documentation shows that not 
all the physical therapy goals which appear to be reasonable have been met and it is documented that the 
enrollee is meeting some short-term goals and making progress. Therefore, 10 additional physical therapy 
sessions are medically necessary as assessment and treatment by a professional therapist would be required to 
meet the documented goals. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have been met. Therefore, we decided that the Plan has to pre-
approve 10 physical therapy visits.  
 
 
 
 
 
 
 
 
 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 pre-approve Retacrit. 
 
You asked the Plan to pre-approve Retacrit. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the clinical value and effectiveness of Retacrit in the setting of blood loss anemia 
secondary to long term anticoagulation use has not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Retacrit. Our reviewer says that 
Retacrit is not medically reasonable and necessary. Retacrit is not FDA-approved for your diagnosis. Retacrit is 
not indicated for the treatment of iron deficiency anemia. The use of Retacrit is not supported by one of the 
major drug compendia or by clinical research that appears in a CMS-approved medical journal. Our physician 
reviewer found that your condition does not meet criteria for coverage of Retacrit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit.