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

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on November 
17, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you are on a tight financial 
budget and this copayment will create a hardship. The Plan denied your request. The Plan says the copayment 
was applied 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 $350 per 
trip for Medicare-covered ambulance services. 
 
 
  You have been asked to pay $350 for ambulance services. Ambulance services 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 services 
provided on November 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the various services provided to the enrollee on October 15, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the claim was coded incorrectly. 
 
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 the denied codes is: 
 
CPT 49000: 
 
Exploratory laparotomy, exploratory celiotomy with or without biopsy(s) (separate procedure) 
 
CPT 44050: 
 
Reduction of volvulus, intussusception, internal hernia, by laparotomy  
CPT 15273: 
 
Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq 
cm; first 100 sq cm wound surface area, or 1% of body area of infants and children 
 
CPT 15274: 
 
Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq 
cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of 
infants and children, or part thereof (List separately in addition to code for primary procedure) 
 
CPT 97606: 
 
Negative pressure wound therapy (eg, vacuum assisted drainage collection), utilizing durable medical 
equipment (DME), including topical application(s), wound assessment, and instruction(s) for ongoing care, per 
session; total wound(s) surface area greater than 50 square centimeters 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT CPT 44050, the 
operative report does not include documentation of volvulus, intussusception reduction, and therefore cannot be 
verified. In terms of CPT 49000, Medicare guidelines state that a diagnostic procedure shall not be reported 
with a surgical procedure, when performed same anatomic location.  When increased procedural services are 
performed, then only the appropriate modifier would be appended to the more extensive procedure. In terms of 
CPT 15273 and 15274, the operative report does not include documentation of application of skin substitute, 
and therefore cannot be verified. In terms of CPT 97606, when a wound vac is applied during surgery, then it is 
not reported separately from the surgical procedure. 
 
We looked at this coder's review, the file, and Medicare rules. 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 various services provided to the enrollee on October 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nexletol. 
 
You asked the Plan to pre-approve Nexletol. You say that the records provided support the need for the 
requested drug. The Plan denied your request. The Plan says the enrollee does not have coverage for outpatient 
prescription drugs under this contract. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nexletol.  
 
Benefits for Nexletol may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the wrist endoscopy surgery (29848) 
provided on December 7, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service 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 $275 
copayment for each Medicare-covered outpatient surgery at a hospital outpatient facility.  
 
 You have been asked to pay a $275 copayment for the Medicare-covered outpatient surgery provided at a 
hospital outpatient facility. 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 wrist endoscopy 
surgery (29848) provided on December 7, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twenty-six (26) additional routine transportation trips 
(A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you are entitled to 
additional transportation rides because you were told that you could use this benefit to the grocery store, the 
gym, all separately, not in one benefit. You also say now all your rides are exhausted and you need to go to 
your medical appointments weekly for therapy. The Plan denied your request. The Plan says you have 
exhausted your 2022 benefit for routine transportation trips. 
 
 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 36 one-way trips per year trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve twenty-six (26) additional routine transportation trips 
(A0120).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an initial nursing facility visit (99305) 
provided on December 6, 2021. 
 
You asked the Plan to waive the deductible for the initial nursing facility visit. You say that the services should 
be covered as you disagree with the charges. The Plan denied your request. The Plan says the deductible 
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. Your 
contract with the Plan says that there is a $1,484 deductible which applies to Skilled Nursing Facility (SNF) 
Care.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category Skilled 
Nursing Facility (SNF) Care. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $1,484 deductible which applies to Skilled Nursing Facility (SNF) Care. This cost sharing is a 
contractual obligation that had not been met at the time the initial nursing facility visit was received on 
December 6, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the initial 
nursing facility visit (99305) provided on December 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs and computed tomography (CT) scan provided in an outpatient setting from October 1, 2021, to October 4, 2021.

You asked the Plan to pay for the outpatient services. You say that you do not feel that you are liable for this bill. The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says there is a $225 copayment for the CT scan when received in network.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. The rules also 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 CT scan.

You have been asked to pay a $225 copayment for the CT scan. CT scan 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 pay for the self-administered drugs and computed tomography (CT) scan provided in an outpatient setting from October 1, 2021, to October 4, 2021. 

Benefits for the outpatient services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for advance care planning services provided to the enrollee on 
March 23, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99497 25 (1 unit) remains not supported. 
 
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 99497 is "Advance care planning including the 
explanation and discussion of advance directives such as standard forms (with completion of such forms, when 
performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the 
patient, family member(s), and/or surrogate." 
 
 
 
 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the procedure report for this date of 
service does not include documentation of advance care planning, including explanation and discussion, and 
therefore cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. 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 advance care planning services provided to the enrollee on March 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cosentyx Pen. 
 
You asked the Plan to pre-approve a Cosentyx Pen. You say that the records provided support the need for the 
requested drug. The Plan denied your request. The Plan says the enrollee's contract does not cover outpatient 
prescription drugs. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve a Cosentyx Pen.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (81546) rendered by the out-of-
network (OON) provider on August 24, 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 laboratory service (81546) rendered by the out-of-network (OON) provider on 
August 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the chemical cauterization of granulation 
tissue (17250) and the open wound debridement (97597) provided on September 3, 2021 and September 17, 
2021. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
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 
copayment for each Medicare-covered outpatient hospital facility surgery.  
 
 You have been asked to pay $347.28 ($173.64 x 2) for the Medicare-covered outpatient hospital facility 
surgeries provided. This amount includes the total of the Plans allowed amounts for the surgeries provided, 
which is less than the applicable copayments 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 the copayments 
for the chemical cauterization of granulation tissue (17250) and the open wound debridement (97597) provided 
on September 3, 2021 and September 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the trimming of non-dystrophic nails (11719) and the nail 
debridement (11720) rendered by the out-of-network (OON) provider on January 25, 2022. 
 
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 trimming of non-dystrophic nails (11719) and the nail debridement (11720) 
rendered by the out-of-network (OON) provider on January 25, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services provided at a 24-hour facility, in addition to basic 
service (99053) provided on November 14, 2021. 
 
  You asked the Plan to pay for services provided at a 24-hour facility, in addition to basic service (99053). You 
say that the patient was seen twice on the same date of service at two different times by two different providers. 
You say that the claim should be reprocessed accordingly for payment. The Plan denied your request. The Plan 
says CPT code 99284 has been paid and CPT code 99053 remains denied as bundled service are not eligible for 
separate reimbursement. 
 
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 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of services provided at a 24-hour facility, in addition to basic service (99053) have not been met. Therefore, we 
decided that the Plan does not have to pay for services provided at a 24-hour facility, in addition to basic 
service (99053) provided on November 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a nivolumab injection (J9299) provided on 
November 4, 2021. 
 
You asked the Plan to waive the coinsurance for the nivolumab injection. 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 20% 
coinsurance for Medicare Part B prescription drugs, and the administration of them.  
 
 
  You have been asked to pay a 20% coinsurance for the nivolumab injection (allowed is $6927.13 x 20% = 
$778.91). Nivolumab injections fall within the Medicare Part B prescription drugs benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for a nivolumab injection (J9299) provided on November 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
from December 15, 2021, to December 27, 2021. 
 
You asked the Plan to waive the copayment for the SNF care. 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 $20 
copayment per day for days 1-20 of Skilled nursing facility (SNF) care.  
 
 
  You have been asked to pay a $240 copayment for 12 days of SNF care ($20 x 12 = $240). 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) care provided from  December 15, 
2021, to December 27, 2021.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve an expandable controller. We decided that the Plan does not have 
to pre-approve a power seat elevation feature.  
 
You asked the Plan to pre-approve an expandable controller. You say that these items are medically necessary. 
The Plan says that the seat elevation is not covered, and you can operate the approved power options through 
their own switches. 
 
We decided that the Plan has to pre-approve an expandable controller.  
 
The Plan follows Medicare rules. Medicare rules say that an expandable controller is covered when it is 
medically necessary for any of the functions described in the 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 an expandable controller. Our reviewer 
says that the requested expandable controller is medically necessary. Our physician reviewer found the records 
show that you need to control the power functions through a joystick due to progressive upper limb weakness.  
 
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 expandable controller have been met. Therefore, we decided that the Plan 
has to pre-approve an expandable controller.  
 
We also decided that the Plan does not have to pre-approve a power seat elevation feature. 
 
The Plan follows Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and power 
standing feature (E2301) are non-covered because they are not primarily medical in nature. 
 
We looked at the file and Medicare rules. A power seat elevation feature is not considered medical in nature 
and is not covered. Based on this information, we decided that Medicare rules for coverage of a power seat 
elevation feature have not been met. Therefore, we decided that the Plan does not have to pre-approve a power 
seat elevation feature. 
 
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.