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

 
We decided that the Plan does not have to waive the copayment for the diagnostic radiology provided on 
September 1, 2021. 
 
You asked the Plan to waive the copayment for the diagnostic radiology. You say that you would like to appeal 
the copayment for the services rendered. The Plan denied your request. The Plan says the proper copayment 
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 $125 
copayment for Medicare-covered radiological diagnostic services, not including X-rays, performed in a 
physicians office or at a free-standing facility. The total copayment charged was $120.40 which is less than the 
$125 copayment. 
 
  You have been asked to pay a $120.40 copayment for the diagnostic radiology. The diagnostic radiology 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 diagnostic radiology provided on September 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120), bitewing x-rays (D0272), and 
prophylaxis (D1110) provided on June 11, 2021. 
 
You asked the Plan to pay for the dental services. You say that you have been seeing this dentist for 20 years. 
You say that you were told by a plan representative that the provider was in network. You say that you just 
found out that they provider does not accept your specific plan. You also say that this should not be denied 
because of confusing technicalities. The Plan denied your request. The Plan says the provider in this case is out 
of network. The Plan also says that dental services received out of network are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage, dental services received out of network  
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
the oral exam (D0120), bitewing x-rays (D0272), and prophylaxis (D1110) provided on June 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement services provided on October 27, 2021, 
billed with code 11000-59. 
 
You asked the Plan to pay for the debridement services as billed. You say that coding rules allow for payment 
of both code 11000 and the application of the skin substitute graft. The Plan denied your request. The Plan says 
the records do not support that the billed services were performed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 11000 is debridement of extensive eczematous or infected skin; up to 10% of body surface. 
 
We find that CPT code 11000 is not supported in the medical record. Specifically, the record does not clearly 
describe the debridement services that were provided. It is not clear that the services provided could be 
considered extensive, nor that they were performed on eczematous or infected skin. Based on this information, 
we decided that Medicare rules for coverage of the debridement services as billed have not been met. 
Therefore, we decided that the Plan does not have to pay for the debridement services provided on October 27, 
2021, billed with code 11000-59.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection power wheelchair accessory 
(E2311). 
 
You asked the Plan to pre-approve an electronic connection power wheelchair accessory. You say that the 
requested electronic connection power wheelchair accessory (E2311) is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for the requested electronic connection power 
wheelchair accessory (E2311). 
 
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 an electronic connection power 
wheelchair accessory. Our reviewer says that the enrollee does not meet criteria for the requested electronic 
connection power wheelchair accessory (E2311). Our physician reviewer found based on the medical records 
provided there is no documentation that the enrollee meets the above Local Coverage Article criteria for the 
requested electronic connection (E2311). As the approved power wheelchair has only one power option (tilt), 
the requested electronic connection (E2311) is not 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 an electronic connection power wheelchair accessory have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electronic connection power wheelchair 
accessory (E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral sacroiliac (SI) joint lateral branch 
radiofrequency ablation. 
 
You asked the Plan to pre-approve bilateral SI joint lateral branch radiofrequency ablation. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are covered when specific 
criteria are met. 
 
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 bilateral SI joint lateral branch 
radiofrequency ablation. Our reviewer says that the services are not medically necessary.  Our physician reviewer found the review has determined that the requested SI joint radiofrequency ablation is 
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 bilateral SI joint lateral branch radiofrequency ablation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve bilateral sacroiliac (SI) joint lateral branch 
radiofrequency ablation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation - per site 
(D7953) provided November 10, 2021. 
 
You asked the Plan to pay for the bone replacement graft. You say that you would like this service covered. 
The Plan denied your request. The Plan says this service is not covered under your plan. Additionally the Plan 
states that you were not provided any incorrect benefit information prior to the services being rendered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the bone replacement graft for 
ridge preservation - per site (D7953) provided November 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive hereditary cardiovascular genetic panel 
(81401, 81403, 81404, 81405, 81406, 81407, 81408, 81479) provided on November 8, 2021. 
 
You asked the Plan to pay for a comprehensive hereditary cardiovascular genetic panel. You say that this was 
medically necessary. The Plan denied your request. The Plan says this is not covered.  
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular 
(CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients. 
 
We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not 
covered. Based on this information, we decided that Medicare rules for coverage of a comprehensive hereditary 
cardiovascular genetic panel have not been met. Therefore, we decided that the Plan does not have to pay for a 
comprehensive hereditary cardiovascular genetic panel (81401, 81403, 81404, 81405, 81406, 81407, 81408, 
81479) provided on November 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on December 
9, 2021. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that you were not at the 
hospital that day. You say you had the test done at the cancer center. 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 $10 
copayment per day, per provider, for laboratory services.  
 
You have been asked to pay a $10 copayment for the laboratory services. Please note that the copayment 
applies regardless of the service location. The laboratory services fall 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 laboratory services provided on December 9, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of 
abdomen and pelvis provided on October 26, 2021. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you were told on the day of 
registration that you would not be required to pay a copayment. You also say that the test was done at a 
freestanding outpatient facility rather than a hospital and the EOC shows a zero-dollar copayment. The Plan 
denied your request. The Plan says you have been charged the correct cost sharing amount. The Plan also says 
per the EOC guideline the CT scan is either in a non-hospital or hospital setting. 
 
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 $200 copayment for in-network CT scans at a hospital facility.  
 The record shows the CT scan was performed at a hospital facility. The enrollee has been asked to pay a $200 
copayment for a CT scan. A CT scan falls within the Outpatient Diagnostic Tests and Therapeutic Services and 
Supplies benefit category. This means that the enrollee has been 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 a computed 
tomography (CT) scan of abdomen and pelvis provided on October 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an aspiration and/or injection of fluid from 
large joint (20610) and a hyaluronan or derivative, synvisc or synvisc-one, for intra-articular injection (J7325) 
provided on December 1, 2021. 
 
You asked the Plan to waive the copayment for an aspiration and/or injection of fluid from large joint and a 
hyaluronan or derivative, synvisc or synvisc-one, for intra-articular injection. You say that you were told that 
you do not owe the amount, and that you had no copayment. 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 $40 
copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse 
practitioner or physician's assistant or other non-physician health care professionals in a specialist's office.  
 
You have been asked to pay a $40 copayment for an aspiration and/or injection of fluid from large joint and a 
hyaluronan or derivative, synvisc or synbisc-one, for intra-articular injection. An aspiration and/or injection of 
fluid from large joint and a hyaluronan or derivative, synvisc or synbisc-one, for intra-articular injection fall 
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 an aspiration and/or injection of fluid from large joint (20610) and a 
hyaluronan or derivative, synvisc or synvisc-one, for intra-articular injection (J7325) provided on December 1, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) and the annual depression screening 
(G0444) rendered by the out-of-network (OON) provider on December 7, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the office visit (99213) and the annual depression screening (G0444) rendered by 
the out-of-network (OON) provider on December 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network 
(OON) provider on November 17, 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 (99214) rendered by the out-of-network (OON) provider on  
November 17, 2021.
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 August 17, 2021, to September 21, 2021. 
 
You asked the Plan to waive the copayment for skilled nursing facility (SNF) services. You say that you were 
informed that there is a copayment of $184 per day on days 21 through 50 of a say at rehabilitation, and since 
your stay was prolonged due to your medical condition and in avoidance of returning to the hospital, you are 
appealing this daily copayment. You also say that you are on a fixed income and do not have the finances to 
pay the $2,760 copayment that the facility is requiring. 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 $184 
copayment each day for days 21 to 50 for skilled nursing facility (SNF) care.  
 
You have been asked to pay a $184 copayment each day for days 21 to 35 for skilled nursing facility (SNF) 
services, which is a total of $2,760 ($184 copayment x 15 days = $2,760). Skilled nursing facility (SNF) 
services fall within the skilled nursing facility (SNF) 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 skilled nursing facility (SNF) services provided from August 17, 2021, to 
September 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 We reviewed the file and the Medicare rules. We find that the enrollee is outside the age range listed for the 
LDCT scan. Therefore, we decided that the Plan does not have to pre-approve a low dose computed 
tomography (LDCT) scan for lung cancer screening.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Echocardiography, transthoracic, real-time with 
image documentation (2D), includes M-mode recording, when performed (CPT 93350). 
 
You asked the Plan to pre-approve an Echocardiography, transthoracic, real-time with image documentation 
(2D), includes M-mode recording, when performed. The Plan denied your request. The Plan says the member 
does not have any indication for the requested procedure based on Medicare criteria as defined by the LCD. 
 
The Plan follows Medicare rules.  
 
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 an Echocardiography, transthoracic, 
real-time with image documentation (2D), includes M-mode recording, when performed. Our reviewer says 
that an Echocardiography, transthoracic is not medically necessary. Our physician reviewer found the recent 
ECG is unchanged compared with a prior ECG performed in 2018. The enrollees pre-test probability for an 
abnormal test is low and there is no documentation that the ECG shows an uninterpretable pattern. There is no 
evidence provided that would support the need for stress echocardiography based on current guidelines. In 
summary, there is insufficient documentation to support the medical necessity for the requested stress 
echocardiography in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Echocardiography, transthoracic, real-time with image documentation (2D), 
includes M-mode recording, when performed have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Echocardiography, transthoracic, real-time with image documentation (2D), includes 
M-mode recording, when performed (CPT 93350).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a specialist office visit and implant 
evaluation and programming services provided from June 16, 2021, to September 20, 2021. 
 
You asked the Plan to waive the copayments for the specialist office visit and implant evaluation and 
programming services. You say that the provider billed you $400 and you would like the Plan to cover some of the charges. 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 $45 
copayment for services obtained from a specialist. 
 
Your contract with the Plan also clearly says that you must pay a $30 copayment for non-radiological 
diagnostic services. 
 
You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls 
within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. You have also 
been asked to pay a $30 copayment for each of the 5 implant evaluation and programming services. The 
implant evaluation and programming services fall within the Outpatient Diagnostic Tests and Therapeutic 
Services and Supplies benefit category. The total for all visits is $195. 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 a specialist office visit and implant evaluation and programming services provided from June 
16, 2021, to September 20, 2021.