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

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services (A0428, 
A0425) provided on February 22, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation 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 $210 
copayment for Ambulance services.  
 
 
  You have been asked to pay a $210 copayment for the ambulance transportation services. 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 transportation services (A0428, A0425) provided on 
February 22, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy (45380) provided on 
February 9, 2022. 
 
You asked the Plan to waive the copayment for the colonoscopy. 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 $200 
copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
 
  You have been asked to pay a $200 copayment for the colonoscopy. Colonoscopies fall 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 copayment for a colonoscopy (45380) provided on February 9, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair ramp. 
 
You asked the Plan to pre-approve the wheelchair ramp. You say that the ramp is necessary. The Plan denied 
your request. The Plan says this would be considered a convenience item primarily hygienic in nature or a 
device that is not primarily medical in nature and not covered under Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. 
This item is available to the general public and would be helpful even to those who are not sick or injured. 
Therefore, we decided that the Plan does not have to pre-approve the wheelchair ramp.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a hyaluronan acid injection provided on 
August 19, 2021. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you were charged for out-of-
network services. 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.  
 
You have been asked to pay $14.61, which is 20% of the allowed amount for the injection ($73.04 allowed amount x 20% coinsurance = $14.61). 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 hyaluronan acid injection provided on 
August 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a hyaluronan acid injection provided on 
August 25, 2021. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you were charged for out-of-
network services. 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.  
 
You have been asked to pay $14.61, which is 20% of the allowed amount for the injection ($73.04 allowed amount x 20% coinsurance = $14.61). 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 hyaluronan acid injection provided on 
August 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an orthosis (L3962, L0650) provided June 9, 2021. 
 
You asked the Plan to pay for the orthosis. You say that the service was medically necessary. The Plan denied 
your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. There is no itemized shipping invoice. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for an orthosis (L3962, L0650) provided June 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you are currently unable 
to attend any of your doctor appointments. You do not have any other means of transportation. You are asking 
for reconsideration for the additional transportation trips that have been denied. The Plan denied your request. 
The Plan says you have exhausted the maximum benefit of 60 one-way trips per year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (99212) provided on 
October 14, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. 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 $45 
copayment for Physician/Practitioner services, including doctors office visits.  
 
 
  You have been asked to pay a $45 copayment for the specialist office visit. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a specialist office visit (99212) provided on October 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that you are receiving appropriate in-patient acute care and do not 
require transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. You do not 
require services at the LTACH that are not available at the acute care hospital where you are currently 
receiving care. All medically necessary care is being provided in the current acute care setting. Our physician 
reviewer found that your condition does not meet Medicare criteria for LTACH services. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve TMS (CPT code(s): 90867 and 90868). 
 
You asked the Plan to pre-approve the TMS. You say that the services are necessary. The Plan denied your 
request. The Plan says you do not have psychotic symptoms (such as hallucinations). 
 
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 TMS. Our physician reviewer found 
you carry a diagnosis of major depressive disorder; however, there is no documentation of depressive rating scales, previous electroconvulsive therapy (ECT) and no evidence-based psychotherapy documented during 
this course of depression. It does not appear that TMS therapy is considered medically necessary for you as you 
do not meet the criteria for LCD L34988. 
 
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 TMS have not been met. Therefore, we decided that the Plan does not have 
to pre-approve TMS (CPT code(s): 90867 and 90868).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received from January 5, 2022, to 
January 7, 2022. 
 
You asked the Plan to pay for the drugs. You say that this was medically necessary. The Plan denied your 
request. The Plan says this is not a covered under the Part B or medical 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 pay for self-administered drugs received 
from January 5, 2022, to January 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you had a seizure from chemotherapy and it partially 
paralyzed you. You say that you cannot go to the bathroom or walk without assistance from nursing staff. The 
Plan denied your request. The Plan says according to the available records, you do not meet all the required 
Medicare criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were 
admitted for altered mental status and right facial weakness. Medical problems are stable. While you have a 
need for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (CPT code E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that a total electric hospital bed is 
necessary. The Plan denied your request. The Plan says a total electric hospital bed is not covered by the health 
plan or Medicare. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of a total electric hospital bed have not been met. The rules say a total 
electric hospital bed (E0265 is not covered; the height adjustment feature is a convenience feature. Total 
electric beds will be denied as not reasonable and necessary. Therefore, we decided that the Plan does not have 
to pre-approve a total electric hospital bed (CPT code E0265).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan 
denied your request. The Plan says there is no evidence that bilevel positive airway pressure (BiPAP) has been 
tried, and failed, at home. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician 
reviewer found there is documentation that this patient has chronic respiratory failure consequent to chronic 
obstructive pulmonary disease. Based on the medical records provided there is inadequate documentation that 
the ventilator at issue meets Medicare criteria for medically necessary and reasonable for this patient. Records 
do not show trial and failure of BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair, group 3 standard, multiple power 
option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (CPT code K0861) and 
the requested accessories. 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the enrollee does not have a medical need for a Group 3 power wheelchair (PWC) with 
the requested power option(s)/feature(s). 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 DME. Our physician reviewer found there is no documentation that the enrollee meets Medicare criteria for the requested group 3 power 
wheelchair with multiple power options and power tilt, recline and elevating legrests. Records do not document 
that the enrollee has past or present pressure sores, is unable to weight shift, requires intermittent bladder 
catheterization, has increased tone or muscle spasticity. Records do not document a musculoskeletal condition 
or the presence of a cast or brace which prevents 90-degree flexion at the knee or significant lower extremity 
edema or meet the criteria for a reclining back on the wheelchair. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight 
capacity up to and including 300 pounds (CPT code K0861) and the requested accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the stem cell procedure (CPT code(s): Q4192 and 
20610). 
 
You asked the Plan to pre-approve the stem cell procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. We looked at the file and Medicare rules. Based on this information, we decided that there is 
insufficient information in the record to determine if Medicare rules for coverage of the stem cell procedure 
(CPT code(s): Q4192 and 20610). have been met. you did not submit medical records to support medical 
necessity. Therefore, we decided that the Plan does not have to pre-approve the stem cell procedure (CPT 
code(s): Q4192 and 20610).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the osteogenesis stimulator, electrical, non-invasive, 
other than spinal applications (CPT code E0747). 
 
You asked the Plan to pre-approve the osteogenesis stimulator. You say that the bone growth stim is needed to 
help heal non-union of right foot and the enrollee is post-op arthrodesis trip right foot on March 30, 2022. The Plan denied your request. The Plan says there is no medical documentation submitted indicating failed fusion, 
where a minimum of nine (9) months has elapsed since the last surgery. 
 
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 osteogenesis stimulator. Our 
physician reviewer found detailed documentation is not evident regarding a non-union of a long bone fracture. 
It has not been 9 months since the enrollee's last surgery. Moreover, serial radiographs do not corroborate a 
non-union separated by 90 days. There is no compelling rationale presented or extenuating circumstances noted 
to support the medical necessity of this request as an exception to guidelines. Therefore, the medical records 
provided do not meet the requirements listed in the NCD for Medicare Coverage. 
 
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 osteogenesis stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the osteogenesis stimulator, electrical, non-invasive, other than spinal 
applications (CPT code E0747).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient surgery you had on November 
1, 2021, and November 4, 2021, at an ambulatory surgical center. 
 
You asked the Plan to waive the copayments for the outpatient surgeries. You say that these two procedures 
failed and you have to have a third one.  You do not think you should have to pay a copayment for failed 
procedures. The Plan denied your request. The Plan says you were charged these copayments 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 $150 
copayment for surgery or other services at an ambulatory surgical center.  
 
You have been asked to pay a $150 copayment for the outpatient surgeries. The outpatient surgeries fall within 
the surgery or other services at an ambulatory surgical center benefit category. These copayments apply 
regardless of the success of the procedure. 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 outpatient 
surgery you had on November 1, 2021, and November 4, 2021, at an ambulatory surgical center.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70554 billed for date of service February 6, 
2022. 
 You asked the Plan to pay for procedure code 70554. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70554 is bundled into payment for 
code 70551. 
 
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 70554 
is a column II code to column I code 70551. 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 70554 billed for date of service February 6, 
2022.