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

 
We decided that the Plan does not have to waive the copayment for Injections on November 23, 2021. 
 
You asked the Plan to waive the copayment for Injections. You say that you would like to appeal the cost 
share. The Plan denied your request. The Plan says the cost share 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 20% 
coinsurance for Injections. The total allowed amount of the Injections is $238.80, resulting in a coinsurance 
amount of $47.76. 
 
You have been asked to pay 20% coinsurance for Injections. Injections 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 copayment for Injections on 
November 23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises, therapeutic activities, and therapeutic 
procedures provided on February 1, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for therapeutic exercises, therapeutic activities, and therapeutic procedures. You say 
that the denials do not acknowledge the medical necessity of the medical services provider, and the doctor's 
approval of the rehabilitation services was obtained as evidenced by the Plan's doctor request. The Plan denied 
your request. The Plan says the provider is out-of-network, and the services were not urgent/emergent. 
 
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 therapeutic exercises, therapeutic activities, and 
therapeutic procedures provided on February 1, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pharmacogenetic testing (CPT code(s): 81230, 
81240, 81241, 81249, 81291, 81408, and 81335) provided on April 11, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
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 the laboratory services have not been met. Medicare denies 
coverage when a laboratory assays two or more genes in a patient in parallel. Those two or more genes will be 
considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be 
submitted for the panel.  Therefore, we decided that the Plan does not have to pay for the molecular pharmacogenetic testing (CPT 
code(s): 81230, 81240, 81241, 81249, 81291, 81408, and 81335) provided on April 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the service provided between 10:00 pm and 8:00 am at a 24-
hour facility (CPT code 99053) provided on September 6, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT code 99053 which has a status indicator of 'B' on the CMS Physician Relative Value File, and is always bundled into payment for other services not specified and no separate payment is made per Medicare. 
Therefore, we decided that the Plan does not have to pay for the service provided between 10:00 pm and 8:00 
am at a 24-hour facility (CPT code 99053) provided on September 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the automatic external defibrillator 
provided by a network provider on December 17, 2021. 
 
You asked the Plan to reduce the coinsurance for the automatic external defibrillator. You say that you were 
told you would pay 10% coinsurance for the life vest. 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 20% 
coinsurance for durable medical equipment, oxygen/oxygen equipment and related supplies.  
 
 You have been asked to pay $633.73 which is 20% of the allowed amount for the automatic external 
defibrillator. The allowed amount is $3,168.69. ($3,168.69 x 20% = $633.73). The automatic external 
defibrillator 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 reduce the coinsurance for the automatic external defibrillator provided by a network 
provider on December 17, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy with lesion 
removal provided on June 18, 2021. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you received multiple 
bills and you tried contacting customer service with no success. 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 $125 
copayment for a diagnostic colonoscopy at an ambulatory surgical center.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$125 copayment for a diagnostic colonoscopy. A diagnostic colonoscopy 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 a diagnostic colonoscopy with lesion removal provided on June 18, 2021.  
 
Your complaint about the customer service is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a hip injection provided on February 4, 
2022. 
 
You asked the Plan to waive the copayment for the injection. You say that you were not aware of any charges 
at the time of the procedure. 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 $325 
copayment for each outpatient hospital visit.  
 
You have been asked to pay $254.50, which is less than the $325 copayment for the injection. The injection 
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 copayment for a hip injection provided on February 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the specialist office visit provided by a 
contracted provider on November 22, 2021. 
 
You asked the Plan to reduce the copayment for the specialist office visit. You say that you were told that the 
cost of your visit would be $35. You say the extra $15 would be a financial hardship. 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 $50 
copayment for a standard network specialist visit.  
 
 You have been asked to pay a $50 copayment for the specialist office visit. The specialist office visit falls 
within the Physician/Practitioner services, including doctors office visit benefit category. The record shows 
the provider is a part of the standard network. 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 the 
specialist office visit provided by a contracted provider on November 22, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy (45378) provided on 
January 25, 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 $225 
for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers.  
 
 You have been asked to pay a $225 for the colonoscopy. Colonoscopies 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 copayment for a colonoscopy (45378) provided on January 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection procedure for hip arthrography; with anesthesia 
(CPT code 27095-RT and 27095-59-LT) provided on January 5, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT code 27095-RT and 27095-59-LT, exceed the allowable UOS of 1 for the same date of service. Per the 
MAI indicator of "2", 27095-RT and 27095-59-LT were not billed correctly per the bilateral surgery indicator 
of "1". Therefore, we decided that the Plan does not have to pay for injection procedure for hip arthrography; 
with anesthesia (CPT code 27095-RT and 27095-59-LT) provided on January 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on October 10 to November 
8, 2020. 
 
You asked the Plan to pay for home health services. You say that the requested services were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that each patient must receive the home health 
services that are written in an individualized plan of care signed by a doctor of medicine, osteopathy, or 
podiatry or allowed practitioner acting within the scope of his or her state license, certification, or registration. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met.  
 Specifically, the case record does not contain an individualized plan of care signed by a doctor of medicine, 
osteopathy, or podiatry or allowed practitioner acting within the scope of his or her state license, certification, 
or registration. Therefore, we decided that the Plan does not have to pay for home health services provided on 
October 10 to November 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for treatment with Avastin injection provided on March 8, 2021. 
 
You asked the Plan to pay for Avastin injection. You say that you have provided records to support the service 
billed. The Plan denied your request. The Plan says rules for payment have not been met because the service at 
issue was billed with the incorrect HCPCS code. 
 
The Plan must follow Medicare rules. Medicare rules say that HCPCS code J7999 should be reported for 
intravitreal bevacizumab for administration in the office setting. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Avastin injection have not been met. Specifically, treatment with intravitreal Avastin 
(bevacizumab) in the office setting was not correctly billed with HCPCS code J7999 in this case. Therefore, we 
decided that the Plan does not have to pay for treatment with Avastin injection provided on March 8, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF services provided from November 4, 2021, through 
December 3, 2021. 
 
You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says Medicare does not 
cover SNF stays if skilled care is not needed on a daily basis. Custodial care is also not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SNF services have not been met. Specifically, we find that the services at issue in this case are 
considered custodial in nature. Therefore, we decided that the Plan does not have to pay for SNF services 
provided from November 4, 2021, through December 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Vision Services provided on September 2, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Vision Services. You say that that you were misinformed about requiring prior 
authorization. The Plan denied your request. The Plan says the provider is out-of-network and it was 
determined these services were not urgent or emergent. 
 
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 Vision Services provided on September 2, 2021 by 
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the knee. 
 
You asked the Plan to pre-approve the knee MRI. You say that you believe that this imaging is needed to find 
out what is going on with your leg. The Plan denied your request. The Plan says there is no clinical reason for 
this imaging at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they 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 knee MRI. Our reviewer says that 
the requested imaging is not medically reasonable and necessary. Our physician reviewer found the enrollee 
has known severe degenerative joint disease of the knee, and the knee is not locked. A trial of physical therapy 
for range of motion is currently needed. MRI is not necessary at this time. 
 
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 knee MRI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI) of the knee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided to the 
enrollee on December 13, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that there should be no 
charge since she was admitted to the hospital immediately. 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 each one-way ambulance trip.  
 
The enrollee has been asked to pay a $250 copayment for the ambulance transportation. Please note that cost 
share waivers for hospital admission only applies to emergency room visit charges, not for the ambulance trip. The ambulance transportation falls within the Ambulance Services 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 ambulance transportation provided to the enrollee on December 13, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Precision Neo testing strips, a non-preferred 
brand product. 
 
You asked the Plan to pre-approve Freestyle Precision Neo testing strips. You say that you would like the Plan 
to reconsider their denial. The Plan denied your request. The Plan says you have not tried and failed the Plan's 
preferred test strips that are covered by the Plan. The Plan says that you have no medical reason per your 
records why you cannot use the preferred test strips covered by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred providers 
for durable medical equipment and supplies. 
 
We looked at the file, the Plan's contract, and Medicare rules. The services at issue are diabetic testing strips 
from a non-preferred brand. The services are available from the Plan's preferred brand. Therefore, we decided 
that the Plan does not have to pre-approve Freestyle Precision Neo testing strips, a non-preferred brand 
product.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 23, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the OON lab services. You say that these services were medically necessary and 
did not require authorization. The Plan denied your request. The Plan says unauthorized, non-plan services are 
not covered. 
 
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. Neither the rendering provider nor the 
ordering provider are network providers with the Plan. 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 lab services provided on November 23, 2021 by an out-of-network (OON) 
provider.