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

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
March 22, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you went to pick up a 
prescription that was missing from your previous visit on March 21, 2022, and this was not a second ER visit. 
The Plan denied your request. The Plan says this cost sharing was charged 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 $60 
copayment for each emergency room visit.  
 
You have been asked to pay a $60 copayment for an emergency room visit. This item/service falls within the 
Emergency 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 an emergency room 
visit provided on March 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided from May 24, 2022, to 
June 16, 2022. 
 
You asked the Plan to pay for chiropractic services. The Plan denied your request. The Plan says while enrolled 
in this Plan, the member must use network providers to receive medical care and services. The only exceptions 
are emergencies, urgently needed services when the network is not available, out-of-area dialysis services, and 
cases in which the Plan authorizes use of out-of-network providers. 
 
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 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 chiropractic services provided from May 24, 2022, to  
June 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial of the IRF admission. 
The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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 that you do not have any complex nursing or rehabilitation needs. Medically 
necessary care can be provided in a different 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 35302 billed for date of service October 5, 
2021. 
 
You asked the Plan to pay for procedure code 35302. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 35302 is bundled into payment for code 35883. 
 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 35302 
is a column II code to column I code 35883. 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 35302 billed for date of service October 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says admission was 
denied as not meeting IRF criteria and 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 you were admitted for weakness, elevated troponin, and pneumonia. Medical 
problems are stable. There are no complex nursing or rehabilitation needs.  
 While you have a need for physical or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. Medically necessary care can be provided in a different 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81301, 81311, 81292, 81276, 81272, 81210, 
81235, 81275, 81321, 81206) provided on September 8, 2021. 
 
You asked the Plan to pay for the lab services. You say that this 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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 81301, 81311, 81292, 81276, 81272, 81210, 81235, 81275, 81321, and 81206 are not 
supported in the medical record. Specifically, the date of service billed does not match the date the specimen 
was collected per the records (August 26, 2021). Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services (81301, 81311, 81292, 81276, 81272, 81210, 81235, 81275, 81321, 81206) provided on September 8, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an urgent care visit provided on May 03, 
2022. 
 
You asked the Plan to reduce the copayment for an urgent care visit. You say that you have always paid a $45 
copayment but were told you owe $70.93 because your lab work was sent to an out-of-network lab. You say 
that you should have been informed of this and you do not feel you should have to pay the balance. The Plan 
denied your request. The Plan says this cost sharing was charged 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 $45 
copayment for urgently needed services. 
 
You have been asked to pay a $45 copayment for an urgent care visit. This item/service falls within the 
urgently needed 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 reduce the copayment for an urgent 
care visit provided on May 03, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (11042) provided on January 12, 2022. 
 
You asked the Plan to pay for the surgical services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code is not separately 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 11042 is not supported in the medical record. Specifically, this code has a global 
surgery period of 10 days. This service is included in the global surgery package of another unit of code 10042 
which was also billed on the same date of service. Based on this information, we decided that Medicare rules 
for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to 
pay for surgical services (11042) provided on January 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 6, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service June 6, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve injection of sclerosant; multiple incompetent veins, same leg 
(36471), 6 units. 
 
You asked the Plan to pre-approve the services. You say that the requested service is necessary for the enrollee. 
The Plan denied your request. The Plan says that the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that a Bilateral Insufficiency Venous Lower Extremity Study Report on 6/6/22 demonstrated marked 
reflux in the right saphenofemoral junction and great saphenous (below knee) veins and marked reflux in the 
left saphenofemoral junction and small saphenous veins. On 8/4/22, the enrollee underwent endovascular 
micro-foam chemical ablation of the left greater saphenous vein. On 8/11/22, the enrollee underwent 
endovascular micro-foam chemical ablation of the left small saphenous vein. A Left Post Ablation Venous 
Lower Extremity Study Report on 8/15/22 demonstrated that the left small saphenous vein was closed. The 
documentation supports that the coverage criteria for sclerotherapy of the right lower extremity have been met 
in this case. The left lower extremity has been successfully treated. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve injection of sclerosant; multiple incompetent veins, same leg (36471), 6 units.  
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 20, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service June 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump. 
 
You asked the Plan to pre-approve a fluid circulating cold pad with pump. You say that you have used the ice 
cuff before and you will be having surgery. You also say that you need this to manage the pain rather than 
taking medication. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump is not 
covered. 
 
We looked at the file and Medicare rules. The requested item is specifically not covered. Based on this 
information, we decided that Medicare rules for coverage of a fluid circulating cold pad with pump have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a fluid circulating cold pad with 
pump.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies provided on April 9, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says medical records were not provided. 
 
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 physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. Review of the file shows that the order and the medical records 
were dated from 2020. The documentation submitted did not include a physician order for the billed date of 
service or for the billed items. 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 the electrical 
stimulator supplies provided on April 9, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance on May 27, 2022. 
 
You asked the Plan to waive the copayment for ambulance. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged 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 $225 
copayment for each separate Medicare-covered ambulance service. Covered ambulance services include fixed 
wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that can provide care if 
they are furnished to a member whose medical condition is such that other means of transportation could 
endanger the persons health or if authorized by the plan. 
 
You have been asked to pay a $225 copayment for ambulance. This item/service 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 on May 27, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an IV infusion provided on May 13, 2022. 
 
You asked the Plan to waive the copayment for an IV infusion. You say that you received a hydration infusion 
therapy that you did not need. You say that you were not asked if you wanted the therapy or informed of how 
much it was going to cost, or you would have refused it. The Plan denied your request. The Plan says this cost 
sharing was charged 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 $375 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges.  
  You have been asked to pay $254.41, which is less than the $375 copayment for an intravenous infusion. This 
item/service 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 waive the copayment 
for an IV infusion provided on May 13, 2022.  
 
Your complaint about not receiving cost information prior to the 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology services coded 88305 provided on 
December 29, 2021. 
 
You asked the Plan to pay for the surgical pathology services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services are not payable 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. 
 
We find that CPT code 88305 is not supported in the medical record. Specifically, this code has a professional 
component/technical component of 1. The enrollee was outpatient on this date of service. This service is not 
separately payable as billed. Based on this information, we decided that Medicare rules for coverage of the 
surgical pathology services have not been met. Therefore, we decided that the Plan does not have to pay for the 
surgical pathology services coded 88305 provided on December 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 31, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service May 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a computed tomography (CT) scan 
provided on June 14, 2022. 
 
You asked the Plan to reduce the copayment for a computed tomography (CT) scan. You say that you are on a 
fixed income and you cannot afford this copayment. The Plan denied your request. The Plan says this cost 
sharing was charged 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 $270 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $270 copayment for a computed tomography (CT) scan. This item/service 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 reduce the copayment for a computed tomography (CT) scan provided on June 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on July 13, 2021. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the copayment 
and would like it to be reconsidered. The Plan denied your request. The Plan says this cost sharing was charged 
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 $45 
copayment for physician/practitioner service. 
 
You have been asked to pay a $45 copayment for a specialist visit. This item/service falls within the 
physician/practitioner service 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 specialist 
visit provided on July 13, 2021.