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

 
We decided that the Plan does not have to waive the copayments for the arthrocentesis, aspiration and/or 
injection, of a major joint or bursa, with ultrasound guidance (20611) provided on August 25, 2021 and 
September 22, 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 $275 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 $500.68 (Plan allowed amounts of $250.34 x 2) for the Medicare-covered 
surgeries provided at an outpatient hospital. This amount is less than the total applicable copayments for the 
services provided. 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 arthrocentesis, aspiration 
and/or injection, of a major joint or bursa, with ultrasound guidance (20611) provided on August 25, 2021 and 
September 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an office visit (99213) provided by an out-
of-network provider on November 5, 2021. 
 
You asked the Plan to waive the coinsurance for an office visit. You say that this provider was considered in-
network for previous services. The Plan denied your request. The Plan says this processed 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). The contract with the Plan clearly says that enrollees must pay 40% 
coinsurance for out-of-network office visits.  
 
The enrollee has been asked to pay a 40% coinsurance for an office visit with an out-of-network provider. 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 coinsurance for an office visit (99213) provided 
by an out-of-network provider on November 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service November 4, 
2021. 
 
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for 76705 is bundled into payment for 93976.  
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service November 4, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve True Metrix brand diabetic test strips (A4253).  
You asked the Plan to pre-approve the True Metrix brand diabetic test strips. You say that the requested test 
strips are medically necessary. The Plan denied your request. The Plan says the True Metrix brand requested is 
not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. 
 
We looked at the file and Medicare rules. No records were provided showing that the plan preferred brand of 
test strips would be unsafe or ineffective for this enrollee. Based on this information, we decided that Medicare 
rules for coverage of the True Metrix brand diabetic test strips have not been met. Therefore, we decided that 
the Plan does not have to pre-approve True Metrix brand diabetic test strips (A4253).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paramedic intercept services provided on July 31, 2021. 
 
You asked the Plan to pay for paramedic intercept services. You say that due to your spouse being non- 
responsiveness, and you called for an ambulance. You say that you never were told it was not a covered service The Plan denied your request. The Plan says paramedic intercept services provided to areas other than rural 
New York are not covered. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for paramedic 
intercept services provided on July 31, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of 
the lower extremity, without contrast material (73721) provided on December 21, 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 $175 
copayment for in-network Medicare-covered diagnostic imaging services.  
 
 
 You have been asked to pay a $175 copayment for the in-network Medicare-covered diagnostic imaging 
service provided. 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 magnetic resonance imaging 
(MRI) of the lower extremity, without contrast material (73721) provided on December 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on November 3, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the drug testing. You say that you were not aware prior authorization was 
required. You say the service was medically necessary. The Plan denied your request. The Plan says no prior 
authorization was obtained. 
 
 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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for drug testing provided on November 3, 2021, by an out-of-
network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for surgical pathology services (88305) 
provided on December 6, 2021. 
 
You asked the Plan to waive the copayment for the surgical pathology services. You say that the services 
should be covered. 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 $325 
copayment for Outpatient hospital services, specifically Nuclear Medicine Services.  
 
 
  You have been asked to pay a $325 copayment for surgical pathology services. Surgical pathology services fall 
within the Outpatient hospital 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 
surgical pathology services (88305) provided on December 6, 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 September 
27, 2021. 
 
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 70450 is bundled into payment for 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 September 27, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physician office visit (99215, 99417) and monitored drug 
administration (J3490) provided on September 2, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for a physician office visit and monitored drug administration. You say that the 
services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules 
for payment for out-of-network care have not been met. 
 
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 a physician office visit (99215, 99417) and 
monitored drug administration (J3490) provided on September 2, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on October 
27, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you were not aware of 
any policy stating you have to pay for a prescription refill. 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 $35 
copayment for each visit with a specialist.  
 
You have been asked to pay $23.20, which is less than the $35 copayment for the specialist office visit. The 
specialist office visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for a specialist office visit provided on October 27, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy performed on 
April 23, 2021. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that you were under the impression 
that the procedure was preventative and you would not have any copayment. 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 per visit for outpatient surgery.   
The file shows that your previous office visit was for a colonoscopy consult, and concerns were addressed for 
constipation and narrowing of stool. Since the colonoscopy was performed as a result of these concerns, the 
procedure is considered diagnostic. Therefore, you have been asked to pay a $250 copayment for the 
colonoscopy. The colonoscopy 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 diagnostic colonoscopy performed on April 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the tympanometry test (92567), the 
comprehensive hearing test (92557), the office visit (99213), and the removal of impacted cerumen (G0268) 
provided on November 3, 2021. 
 
You asked the Plan to waive the deductible. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the deductible has 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 $200 
deductible each year. This is the amount you have to pay out-of-pocket before the plan will pay their share for 
your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your 
covered services. Once you have paid your deductible, the plan will begin to pay their share of the costs for 
covered medical services and you will pay your share (your copayment or coinsurance amount) for the rest of 
the calendar year.    
 
You have been asked to pay $199.28 as you had not previously met the annual deductible amount for this 
calendar year. This is the Plans allowed amount for these services provided. 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 deductible for the tympanometry test (92567), the comprehensive hearing test (92557), the office 
visit (99213), and the removal of impacted cerumen (G0268) provided on November 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve side guards for a wheelchair. 
 
You asked the Plan to pre-approve side guards. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested item does not serve a medical purpose as required by Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve side guards for a wheelchair.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided during the episode of care beginning 
on January 22, 2021. 
 
You asked the Plan to pay for the home health services. You say that the Plan was incorrectly denying both 
RAPs and claims and was unable to locate several claims. It is felt that the services were correctly billed. The 
Plan denied your request. The Plan says that the claim for this episode of care was not submitted within the 
required time frame. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The documentation in the file as submitted by the Plan does not provide 
sufficient information to justify that the final claim for the home health services provided during the episode 
beginning on January 22, 2021 was submitted untimely. There appears to have been miscommunications 
between the Plan and the provider. The Plan did not provide an adequate timeline to support when these claims 
were received. Review of the file fails to demonstrate that the home health agency failed to submit a timely 
claim for these services. Therefore, we decided that the Plan has to pay for the home health services provided 
during the episode of care beginning on January 22, 2021.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care first hour (99291) provided on July 5, 2021, to 
July 7, 2021. 
 
You asked the Plan to pay for critical care services. You say that these services were medically necessary and 
were billed appropriately. The Plan denied your request. The Plan says that code 99291 is not supported in the 
record. The documentation does not support a critical care visit of 30-74 minutes was performed on the billed 
date of service. The documentation does not include the time spent providing this service. 
 
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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-
74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the medical record does not 
provide any indication of how much time was spent providing these services. Based on this information, we 
decided that Medicare rules for coverage of critical care services have not been met. Therefore, we decided that 
the Plan does not have to pay for critical care first hour (99291) provided on July 5, 2021, to July 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an advanced K3 foot and ankle (L5968, L5981). 
 
You asked the Plan to pre-approve an advanced K3 foot and ankle. You say that this is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage of the requested 
equipment have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the requested advanced foot and ankle is covered 
when the enrollee has a functional level of 3 or above. 
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 advanced K3 foot and ankle. Our 
reviewer says that the requested advanced foot and ankle is not medically reasonable and necessary. Our 
physician reviewer found the enrollee is a 71-year-old male with a past medical history of diabetes with a left 
below-the-knee amputation. Based on the medical records provided there is insufficient documentation to 
support that the enrollee is and will be a K3 level ambulator to meet Medicare criteria for the requested 
advanced foot and ankle. Provided records document that use of a cane for longer walks may still be required 
even with the advanced foot and ankle; this is not consistent with K3 level ambulation. Provided medical 
records from the enrollee's physician do not clearly document K3 level ambulation. 
 
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 advanced K3 foot and ankle have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an advanced K3 foot and ankle (L5968, L5981).