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

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on May 19, 2021. 
 
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 there are no modifiers allowed with this code pair. 
 
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 51702 is a column II code to column I code 51700. 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 surgical services provided to the enrollee on May 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator programmer. 
 
You asked the Plan to pre-approve the spinal cord stimulator programmer. You say that a replacement device is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare only pays for replacement equipment 
in case of specific accidents or natural disasters. 
 
We looked at the file and Medicare rules. The device was not lost due to accident or natural disaster. Based on 
this information, we decided that Medicare rules for coverage of the spinal cord stimulator programmer have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal cord stimulator 
programmer.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound care services provided on 
November 5, 2021 to November 12, 2021. 
 
You asked the Plan to waive the copayment for wound care services. You say that you thought this would be a 
specialist charge of $40. The Plan denied your request. The Plan says the copayment amount 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 $275 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges.  
 
 You have been asked to pay a total of $366.64 for two dates of wound care services. A $183.32 copayment for 
each service, which is less than the Plans EOC documented $275 copayment. Wound care services fall within 
the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for wound care services 
provided on November 5, 2021 to November 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization. 
 
You asked the Plan to pre-approve genicular artery embolization. You say that genicular artery embolization is 
medically necessary. The Plan denied your request. The Plan says genicular artery embolization is not 
medically necessary. 
 
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 genicular artery embolization. Our 
reviewer says that genicular artery embolization is not medically necessary. Our physician reviewer found the 
requested genicular artery embolization in this case is not medically reasonable or necessary as current 
literature does not support the use of this procedure in this clinical situation. Studies have not clearly shown 
genicular artery embolization being better than other treatments for severe osteoarthritis. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular artery embolization.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on September 
21, 2021 
 
You asked the Plan to waive the copayment for ambulance services. You say that you did not have any other 
options for transportation. The Plan denied your request. The Plan says the copayment amount 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 $300 
copayment for each Medicare-covered one-way trip via ground ambulance.  
 
 
 
 
 You have been asked to pay a $300 copayment for ambulance services. Ambulance services 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 services 
provided on September 21, 2021
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a magnetic resonance imaging (MRI) of 
the lumbar spine without contrast material (72148) provided on November 17, 2021. 
 
You asked the Plan to reduce the copayment for a magnetic resonance imaging (MRI) of the lumbar spine 
without contrast material. You say that it shows in-network provider, but the copayment in claims is $100 and 
should be $50. The Plan denied your request. The Plan says you were 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 Medicare-covered radiological diagnostic service, not including x-rays, performed in a 
physician's office or at a free-standing facility (such as a radiology center or medical clinic).  
 You have been asked to pay a $100 copayment for a magnetic resonance imaging (MRI) of the lumbar spine 
without contrast material. A magnetic resonance imaging (MRI) of the lumbar spine without contrast material 
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 reduce the copayment for a magnetic resonance imaging (MRI) of the lumbar spine without 
contrast material (72148) provided on November 17, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency department visits provided on 
October 25, 2021, and November 3, 2021. 
 
You asked the Plan to waive the copayment for the emergency department visits. You say that these treatments 
were ordered by the doctors, and you tried to refuse. 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 a $50 
copayment for emergency care.  
 
 
 You have been asked to pay a $96.32 copayment for the emergency department visits, which is less than the 
$100 ($50 copay x 2 visits). The emergency departments visit 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 emergency department visits provided on 
October 25, 2021, and November 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on November 4, 
2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you should only be charged $20 
for a specialist copay. 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 a $25 
copayment for carotid of peripheral vascular ultrasound.  
 
 
 
 You have been asked to pay a $25 copayment for the ultrasound. You were not charged a copay for the 
specialists office visit. The ultrasound 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 the ultrasound provided on 
November 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Telehealth consultation provided on November 7, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Telehealth consultation. You say that according to the letter of appeal, the 
patients are unable to choose an in-network provider as the providers are provided a list of patients who require 
evaluation. The Plan denied your request. The Plan says it was determined the services were not urgent or 
emergent in nature and that the services rendered could have been provided by a participating provider under 
the members plan. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for Telehealth consultation provided on November 7, 
2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204) rendered by the out-of-network 
(OON) provider on December 16, 2021. 
 
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 the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99204) rendered by the out-of-network (OON) provider on  
December 16, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound of the arteries of the legs 
provided on June 8, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that an agent informed you that the 
procedure was preventive and you would not have 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 $155 
copayment for radiological diagnostic services, not including X-rays.  
 
You have been asked to pay a $155 copayment for the ultrasound. The ultrasound 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 ultrasound of the arteries of the legs provided on June 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82310, 82728, 83540, 83550, 83970, 84100) 
provided September 28, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the lab services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that all laboratory services furnished to individuals 
for the treatment of End-stage renal disease (ESRD) are included in the ESRD PPS as Part B services and are 
not paid separately as of January 1, 2011. 
 
We looked at the file and Medicare rules. Payment for this service is included in payment to the ESRD facility 
and the lab services are not separately payable. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services (82310, 82728, 83540, 83550, 83970, 84100) provided September 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power seat elevation system (E2300), electronic 
connection (E2311), harness (E2313), expandable controller (E2377), and mini proportional compact remote 
joystick (E2373). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that the items are medically necessary. 
The Plan denied your request. The Plan says the items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the Plan's cover items that are 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 wheelchair accessories. Our 
reviewer says that the items are not medically necessary. Our physician reviewer found the documentation does 
not reveal that the patient requires other types of proportional input devices (e.g., mini-proportional or compact 
joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head 
array, etc.) The patient does not need a separate display (i.e., for alternate control devices), other electronic 
devices, or an attendant control. The patient has three powered options approved on the power wheelchair but 
the patient's strength and function in the upper extremities are sufficient for the patient to be able to control any 
power options through their own switches. 
 
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 wheelchair accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the power seat elevation system (E2300), electronic connection (E2311), 
harness (E2313), expandable controller (E2377), and mini proportional compact remote joystick (E2373).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Skilled Nursing Facility (SNF) services 
provided from December 1, 2021, to December 10, 2021. 
 
You asked the Plan to waive the copayment for the SNF Services. 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 $160 
copayment per day for days 21-100 for Skilled nursing facility (SNF) care.  
 
 You have been asked to pay a $1,440 copayment for 9 days of SNF care ($160 x 9 = $1,440. 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 Skilled Nursing Facility (SNF) services provided from December 1, 
2021, to December 10, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the future copayment for an upper endoscopy 
 
You asked the Plan to waive the future copayment for an upper endoscopy. You say that you need four upper 
gastrointestinal (GI) procedures done and cannot have them all done in one day. You also say you cannot 
afford a $250 copayment every time for the four procedures. 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 $250 
copayment for outpatient procedures, including an endoscopy.  
 
You have been asked to pay a $250 copayment for an endoscopy. An endoscopy 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 future copayment for an upper endoscopy
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility services. 
 
You asked the Plan to pre-approve the skilled nursing facility services. You say that the services are 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 Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 skilled nursing facility services. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the record shows that 
the beneficiary does not require skilled nursing or therapy services on a daily basis.  
 
 
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 skilled nursing facility services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (36415, 82040, 82565, 84460, 84450, 
86140, 85025, 85652) provided on December 8, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that this provider regularly complies with all 
administrative requirements for payments. The Plan denied your request. The Plan says this is not a network 
provider with the Plan, and they have also determined that these services are not urgent or emergent, nor were 
they 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 laboratory services (36415, 82040, 82565, 84460, 
84450, 86140, 85025, 85652) provided on December 8, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provide by Hooks Shoe Stores on October 30, 
2021. 
 
You asked the Plan to pay for foot orthotics. You say that your physician said you have neuropathy and you 
need the orthotics to be able to walk, without them you wont be walking much longer. 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 provided on October 30, 
2021.