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

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on February 9, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you only received an x-ray so you 
shouldn't be charged for an ultrasound. The Plan denied your request. The Plan says the copayment applied is 
correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $110 
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic). 
  
 
 You have been asked to pay $94.25 copayment which is less than the standard $110 for an ultrasound.  
Ultrasounds 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 an ultrasound provided on February 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a positioning cushion purchased on November 18, 2021. 
 
You asked the Plan to pay for this positioning cushion. You say that the Plan should pay for this item. The Plan 
denied your request. The Plan says the provider you purchased this item from is not a Medicare eligible 
provider. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who is not a Medicare eligible provider. 
This item was purchased from a vendor who is not a Medicare eligible provider. Therefore, we decided that the 
Plan does not have to pay for a positioning cushion purchased on November 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve JAK2 (Janus kinase 2) testing (81279). 
 
You asked the Plan to pre-approve JAK2 testing. You say that BCR-ABL is not indicated for the enrollee. The 
Plan denied your request. The Plan says a negative BCR-ABL test is required for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that for laboratories performing single gene 
technologies, a sequential genetic testing approach is expected. JAK 2 testing is covered after BCR-ABL 
testing is negative. 
 
We looked at the file and Medicare rules. The record does not show that the enrollee has had negative BCR-
ABL testing. Based on this information, we decided that Medicare rules for coverage of JAK2 testing have not 
been met. Therefore, we decided that the Plan does not have to pre-approve JAK2 (Janus kinase 2) testing 
(81279).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home COVID-19 test kit purchased January 13, 2022. 
 
You asked the Plan to pay for this item. You say that the Plan should pay for this test kit. The Plan denied your 
request. The Plan says per the plans COVID-19 policy, coverage applies to eligible tests that are purchased on 
or after February 1, 2022. Therefore, the Plan was unable to pay for this test as this benefit was not in effect at 
the time of your purchase. 
 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. Medicare pays for COVID-19 testing provided by a 
facility or department of health agency for symptom detection or as a healthcare directive. Home tests 
purchased for preventative measures are not covered by Medicare. The Plan did not begin to provide coverage 
for home tests until February 1, 2022, prior to your purchase. Therefore, we decided that the Plan does not have 
to pay for a home COVID-19 test kit purchased January 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tier exception for Monovisc. 
 
You asked the Plan to pre-approve a tier exception. You say that you cannot afford this medication. The Plan 
denied your request. The Plan says that tier exceptions are not available for drugs/devices covered by Part B. 
 
The Plan must follow Medicare rules. Medicare rules say that tier exceptions are only available for Part D 
drugs.  
 
The requested drug is covered under Part B. Based on this information, we decided that Medicare rules for 
coverage of a tier exception have not been met. Therefore, we decided that the Plan does not have to pre-
approve a tier exception for Monovisc.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for tendon sheath incisions performed on 
March 14, 2022. 
 
You asked the Plan to waive the copayment for the incisions. You say that you assumed insurance would cover 
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 a $325 copayment for the incisions. The incisions 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 tendon sheath incisions performed on March 
14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
January 28, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you were 
transferred from the hospital to the rehab facility. 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 $225 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $225 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance Services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
ambulance transportation provided on January 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for INR monitoring and supplies provided 
from December 28, 2021, to February 22, 2022. 
 
You asked the Plan to reduce the copayments for the INR monitoring and supplies. You say that your 
copayments should only be $10. 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 diagnostic procedures and tests.  
 
You have been asked to pay a $45 copayment for each of the 3 visits for the INR monitoring and supplies, for a 
total of $135. The INR monitoring and supplies 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 reduce the copayments for INR 
monitoring and supplies provided from December 28, 2021, to February 22, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for mental health visit provided on January 20, 
2022. 
 
You asked the Plan to waive the copayment for mental health visit. You say that you were told it was only a 
$30 copayment and that's what youre willing to pay. The Plan denied your request. The Plan says the 
copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $55 
copayment for each out of network Medicare covered individual or group therapy visit.  
 
 
 
 You have been asked to pay $55 copayment for the mental health visit. Mental health visits fall within the 
Outpatient mental health 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 mental 
health visit provided on January 20, 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 documentation does not support that the complexity of the enrollee's nursing, 
medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. Skilled services may be provided at a lower level of care. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99254) provided on November 18, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is not 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99254 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code 99254 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the 
services (99254) provided on November 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0127-59-Q8 (trimming of dystrophic nails) 
you received from a podiatrist on December 15, 2021. 
 
You asked the Plan to pay for procedure code G0127-59-Q8. You say that this service was requested by your 
doctor. The Plan denied your request. The Plan says the use of the -59 modifier requires medical records to 
determine if this code is separately payable.  The provider has not supplied to requested medical records. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
The documentation does not show that the service billed with the -59 modifier is a distinct procedural service. 
Specifically, you had both a nail debridement (code 11720) as well as the trimming of dystrophic nails.  
Typically, the payment for the trimming of dystrophic nails in included as part of the nail debridement code, 
and no separate payment is made.  The only exception to that would be the appropriate use of the -59 modifier 
to indicate that the trimming of dystrophic nails was a distinct procedural service. Medical records are required 
to determine if this service meets this criterion.  The Plan has requested medical records from this provider, but 
they have not supplied them.  Without medical records, the use of the -59 modifier cannot be supported, 
meaning that code G0127 would not be separately payable from the debridement code. Based on this 
information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code G0127-59-Q8 (trimming of 
dystrophic nails) you received from a podiatrist on December 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to lower your copayment for each surgery performed from December 9, 
2021, to December 23, 2021. 
 
You asked the Plan to lower your copayment for each surgical procedure performed from December 9, 2021, to 
December 23, 2021. You say that you assumed the copayment would be $35 for a specialist, not $295. The 
Plan denied your request. The Plan says you must pay a $295 copayment for Medicare-covered surgery or 
other services provided to you at an ambulatory surgical center. The Plan also says you must pay a $295 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital. 
 
 
 
 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 $295 
copayment for Outpatient Surgery And Other Medical Services Provided At Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 
You have been asked to pay a $295 copayment for each surgery performed from December 9, 2021, to 
December 23, 2021. The records indicate that you received 3 separate debridement services from December 9, 
2021, through December 23, 2021. Debridement is considered a surgery service. Surgery falls 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 lower your copayment for each surgery 
performed from December 9, 2021, to December 23, 2021.
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 the enrollee's nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
While the enrollee may benefit from physical therapy and occupational therapy, the rehabilitation needs may be 
provided at a lower level of care. 
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for psychotherapy services provided on 
January 25, 2022. 
 
You asked the Plan to reduce the copayment for the psychotherapy services. You say that you were informed 
that your copayment would only be $30. 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 $55 
copayment for each therapy visit with an out-of-network (OON) provider.  
 
The file shows the Plan verified that the provider is not a network provider. Therefore, you have been asked to 
pay a $55 copayment for the psychotherapy services. The psychotherapy services fall within the Outpatient 
Mental Health 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 reduce the copayment for psychotherapy 
services provided on January 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular pathology procedure; physician interpretation and 
report (G0452) provided January 10, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that please review and reprocess for payment. 
The Plan denied your request. The Plan says this service is not a Medicare covered benefit.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The rules say that genetic testing for these genes for all risk factors, 
signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are non-covered except for 
pregnant patients. Based on this information, we decided that Medicare rules for coverage of the laboratory 
services have not been met. Therefore, we decided that the Plan does not have to pay for molecular pathology 
procedure; physician interpretation and report (G0452) provided January 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cystoscopy performed on August 30, 
2021. 
 
You asked the Plan to waive the copayment for the cystoscopy. You say that you do not feel like the procedure 
was a surgery. 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 $250 
copayment for outpatient surgery in an ambulatory surgical center or hospital outpatient facility.  
 
You have been asked to pay a $250 copayment for the cystoscopy. The cystoscopy 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 cystoscopy performed on August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive your copayments for wound care provided January 10, 2022, 
to January 31, 2022. 
 
You asked the Plan to waive your copayments for wound care provided January 10, 2022, to January 31, 2022. 
You say that you were told the provider accepted what the insurance paid. The Plan denied your request. The 
Plan says you must pay your cost share. 
 
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 $295 
copayment for Outpatient Surgery And Other Medical Services Provided At Hospital Outpatient Facilities And 
Ambulatory Surgical Centers.  
 
You have been asked to pay a copayment for wound care. Wound care falls within the Outpatient Surgery And 
Other Medical Services Provided At Hospital Outpatient Facilities And Ambulatory Surgical Centers benefit 
category. For services provided on January 10, 2022, the Plans allowance was $339.43; your copayment is 
$295.  For services provided on January 14, 2022, January 20, 2022, January 24, 2022, and January 28, 2022, the 
Plans allowance was $138.74. For services provided on January 17, 2022, and January 31, 2022, the Plans 
allowance was $176.35. Since the Plans allowances were less than your required copayments, you were only 
asked to pay the lesser amounts for these 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 your copayments for 
wound care provided January 10, 2022, to January 31, 2022.  
 
DATE OF SERVICE BILLED AMOUNT PLAN ALLOWANCE COPAYMENT 
January 10, 2022 $1974.00 $339.43 $295.00 
January 14, 2022   $745.50 $138.74 $138.74 
January 17, 2022   $659.93 $176.35 $176.35 
January 20, 2022   $745.50 $138.74 $138.74 
January 24, 2022   $745.50 $138.74 $138.74 
January 28, 2022   $745.50 $138.74 $138.74 
January 31, 2022   $659.93 $176.35 $176.35