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

 
We decided that the Plan does not have to pay for anesthesia for image-guided procedures (01936) provided on 
June 3, 2021. 
 
You asked the Plan to pay for anesthesia for image-guided procedures. You say that this general anesthesia was 
medically necessary and should be processed for payment. The Plan denied your request. The Plan says the use 
of general anesthesia was not supported for the enrollee's situation. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for anesthesia for image-guided procedures. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the sedation services were not medically indicated and sedation during an 
Epidural Steroid Injection has been shown to have increased risk of morbidity and mortality as well as 
interfering with the results of the injection. The sedation services were not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of anesthesia for image-guided procedures have not been met. Therefore, we 
decided that the Plan does not have to pay for anesthesia for image-guided procedures (01936) provided on 
June 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for remote cardiac rhythm monitoring (93298) 
provided on January 13, 2022. 
 
You asked the Plan to waive the copayment for the remote cardiac rhythm monitoring. You say that the 
services should be covered as you disagree with the charges. The Plan denied your request. The Plan says the 
services should be covered as you disagree with the charges. 
 
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 the remote cardiac rhythm monitoring. Remote cardiac 
rhythm monitoring falls within the Physician/Practitioner services, including doctors office visits benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for remote cardiac rhythm monitoring (93298) 
provided on January 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound debridement services (11042, 
11043) provided on November 12, 2021. 
 
You asked the Plan to waive the copayment for the wound debridement 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 $250 
copayment for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 
 
  You have been asked to pay a $250 copayment for the wound debridement services. Wound debridement 
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 debridement services (11042, 11043) provided on November 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an adult sized transport chair provided 
from July 20, 2021, to January 20, 2022. 
 
You asked the Plan to waive the coinsurance for an adult sized transport chair. You say that you believe that 
you were fraudulently taken advantage of by this provider and were being billed copayments of $12 a month 
for a wheelchair that you were never told would be billed or cost anything. 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 20 
percent coinsurance for durable medical equipment (DME) and related supplies.  
 
You have been asked to pay a total of $56.58 in coinsurance, which is 20 percent of the allowed amount for an 
adult sized transport chair.  
 
 Claim Number: Date of Service: Allowed Amount: 20% Coinsurance: Maximum Out of 
Pocket Met: 
02021203AJJH 7/20/2021 $60 $12  
02021236AIVN 8/20/2021 $60 $12  
02021265ALBB 9/20/2021 $60 $12  
02021295APYV 10/20/2021 $60 $8.58 Met 
0202133701BK 11/20/2021 $60 0 Met 
0202251204US 12/20/2021 $60 0 Met 
0202252704GO 1/20/2022 $60 $12  
 Total: $420 $56.58  
 
 
An adult sized transport chair falls within the durable medical equipment (DME) and related supplies benefit 
category. The record shows that the enrollee reached their maximum out of pocket expense for the Plan year 
2021 on date of service October 2021. The record also shows that the enrollee had not met the maximum out of 
pocket expense for the Plan year 2022. 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 an adult 
sized transport chair provided from July 20, 2021, to January 20, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for chemotherapy administration services 
provided on January 27, 2022, and February 3, 2022. 
 
You asked the Plan to waive the copayments for the chemotherapy administration. You say that you were never 
charged for chemotherapy in the past. 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 $30 
copayment for chemotherapy administration or infusion.  
 
You have been asked to pay a $30 copayment for each chemotherapy administration, for a total of $60. The 
chemotherapy administration 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 copayments for chemotherapy administration services provided on January 27, 
2022, and February 3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durvalumab injection (J9173). 
 
You asked the Plan to pre-approve the injection. You say that you want to appeal the denial for IV 
chemotherapy. The Plan denied your request. The Plan says Durvalumab is not FDA approved as maintenance 
therapy for treatment of stage IVA, metastatic, non small cell lung cancer, and none of the other references 
supports its use for the indication requested. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 injection. Our reviewer says that the 
requested items/services is considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has completed chemo radiation and PET scan shows improved disease and the 
documentation supports that the requested drug is safe and effective and otherwise reasonable and necessary 
for this enrollee. 
 
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 injection have been met. Therefore, we decided that the Plan does not have 
to pre-approve Durvalumab injection (J9173).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crutch substitute (E0118) fluoroscopy (76000) diagnostic 
bone marrow aspiration (38220) Tenotomy (28232) capsulotomy (28270) Open treatment of 
metatarsophalangeal joint dislocation, includes internal fixation (28645) arthrodesis (28740) provided October 
19, 2021. 
 
You asked the Plan to pay for the outpatient surgery. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says service is not supported without the 
required documentation. 
 The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has another 
insurance carrier as primary and the Plan has not received the primary carrier's Explanation of Benefits. The 
records show that the Plan made multiple attempts to obtain the missing information. As the secondary insurer, 
the Plan cannot be held responsible for the outpatient surgery until the primary insurer has denied the claim for 
these services. Therefore, we decided that the Plan does not have to pay for crutch substitute (E0118) 
fluoroscopy (76000) diagnostic bone marrow aspiration (38220) Tenotomy (28232) capsulotomy (28270) Open 
treatment of metatarsophalangeal joint dislocation, includes internal fixation (28645) arthrodesis (28740) 
provided October 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient services provided from January 
7, 2022, to February 7, 2022. 
 
You asked the Plan to waive the copayment for outpatient services. You say that you do not understand the 
charges since your required copayment was made at the time of services. 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 $50 
copayment for laboratory services, a $275 copayment for diagnostic radiology services, a $50 copayment for 
services performed with a specialist and a $300 copayment for Medicare-covered outpatient hospital services. 
 
You have been asked to pay a total of $515.78 for the outpatient services. 
 
Date of Service Service Allowed Amount Standard Copayment Member Liability 
January 7, 2022 Office Visit $143.82 $50 $50 
January 7, 2022 Labs $24.80 $50 $24.80 
January 18, 2022 Myocardial 
Perfusion Imaging 
$1,275.52 $275 $275 
January 31, 2022 Clinic Visit $115.98 $300 $115.98 
February 7, 2022 Office Visit $96.71 $50 $50 
TOTAL:    $515.78 
 
The office visits fall within the Physician/Practitioner Services, Including Doctors Office Visits benefit 
category. The laboratory services and myocardial perfusion imaging fall within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies benefit category. The clinic visit falls within the Outpatient Hospital 
Services benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. You may contact the Plan regarding any amount still owed for each claim. Therefore, we decided that the 
Plan does not have to waive the copayment for outpatient services provided from January 7, 2022, to February 
7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Knee orthosis equipment (L1851) 
provided on January 19, 2022. 
 
You asked the Plan to waive the coinsurance for the Knee orthosis equipment. 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 20% 
coinsurance for Durable medical equipment (DME) and related supplies.  
 
 
  You have been asked to pay a 20% coinsurance for the Knee orthosis equipment (allowed is $1,036.98 x 20% = 
$207.4). Knee orthosis equipment 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 Knee orthosis equipment 
(L1851) provided on January 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient visit (99204, 73564, 20610, J3301) provided 
on July 22, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advance. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the outpatient visit (99204, 73564, 20610, J3301) 
provided on July 22, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomographic angiography of 
the abdomen and pelvis (74174) and the computed tomographic angiography of the chest (non-coronary) 
(71275) provided on March 11, 2022. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the 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 $180 
copayment for advanced imaging services provided at an outpatient hospital.  
 
 You have been asked to pay a $180 copayment for the advanced imaging services provided at an outpatient 
hospital. 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 computed tomographic angiography of the 
abdomen and pelvis (74174) and the computed tomographic angiography of the chest (non-coronary) (71275) 
provided on March 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen equipment provided on November 26, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for oxygen equipment. You say that you didn't know that you didn't have OON 
coverage. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined 
these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for oxygen equipment provided on November 26, 
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 cardiovascular services provided on December 18, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for cardiovascular services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
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 cardiovascular services provided on December 18, 
2021 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 wound care services provided on 
November 5, 2021. 
 
You asked the Plan to waive the copayment for the wound care. You say that the enrollee should not have been 
responsible since the wounds were a result of improper care. The Plan denied your request. The Plan says the 
enrollee was 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $250 copayment for surgery or services provided at an outpatient hospital or ambulatory surgical 
center.  
 
The enrollee was asked to pay a $250 copayment for the wound care. The wound care falls within the 
Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers benefit category. This means that the enrollee was asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon 
enrolling 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.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monovisc. 
 
You asked the Plan to pre-approve Monovisc. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says step therapy criteria have not been satisfied. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Monovisc. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a 
trial of 2 of the preferred products (Euflexx, Supartz, Durolane, and Gelsyn-3) before they will approve the 
requested drug. The case file does not contain documentation of trial and failure of 2 of the preferred products. 
Furthermore, the documentation does not support that 2 of the plan's required drugs would likely be less 
effective, and/or would likely have adverse effects for the enrollee 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 Monovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Monovisc.