Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667, 
E0656) for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says it cannot be said that the segmental pneumatic compression device is reasonable or 
necessary at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that it is not clear that the enrollee has unique characteristics that would indicate the segmented pump 
over a standard pump. The provided records do not document a trial and failure of at least four weeks of 
regular, daily, multiple-hour home usage of the standard pump. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0667, E0656) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guidance for a trigger point injection 
provided to the enrollee on March 14, 2022. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered experimental, investigational, and unproven. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the notes show the area of intended injections was clinically palpated and then ultrasound was used 
for guidance. As the trigger points have no anatomical definition on ultrasound the use of the technology was 
not necessary.  
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve ultrasound guidance for a trigger point injection provided to the enrollee on March 14, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for injections using ultrasound guidance 
provided on October 28, 2021, and November 22, 2021. 
 
You asked the Plan to waive the copayments for injections using ultrasound guidance. You say that you 
received steroid shots on October 28, 2021, and November 22, 2021, which you believe were incorrectly billed 
as surgery. 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 a $390 
copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, 
including but not limited to hospital or other facility charges and physician or surgical charges.  
 
 
  You have been asked to pay a $264.76 copayment for each injection using ultrasound guidance, which is less 
than the $390 copayment ($264.76 x 2 = $529.52). Injections using ultrasound guidance fall within 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 copayments for injections using 
ultrasound guidance provided on October 28, 2021, and November 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72040 billed for date of service November 
23, 2021. 
  You asked the Plan to pay for procedure code 72040. You say that procedure code 72040 was not bundled with 
any other procedure code performed on the same date of service. You say that the medical records should be 
reviewed, and the claim processed for payment. The Plan denied your request. The Plan says payment for code 
72040 is bundled into payment for code 72052. 
 
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 72040 
is a column II code to column I code 72052. 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 72040 billed for date of service November 23, 
2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Orthovisc. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the step therapy requirement is not met. 
 
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 Plan states that the services are not medically necessary because the step 
therapy requirement is not met; however, no medical records were received for review. Without medical 
records, a determination based on medical necessity cannot be supported. Therefore, we decided that the Plan 
has to pre-approve Orthovisc.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on April 19, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that this should be covered. 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 $350 
copayment per date of service at an outpatient hospital facility.  
 
You have been asked to pay $350 copayment for outpatient surgery. Outpatient surgery 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 outpatient surgery provided 
on April 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on July 23, 2021, to 
July 26, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you were not aware of the 
copayment. The Plan denied your request. The Plan says the cost sharing you are being charged 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 a $250 
copayment per day for days 1-3 for inpatient hospital stay. There were 3 days. $250 x 3 = $750. Therefore, 
results in the total cost sharing amount of $750. 
 
You have been asked to pay a $250 copayment per day for inpatient hospital stay. Inpatient hospital stay falls 
within the Inpatient hospital 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 
inpatient hospital stay on July 23, 2021, to July 26, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an outpatient mental health visit provided 
on February 18, 2022. 
 
You asked the Plan to reduce the copayment for an outpatient mental health visit. You say that you demand 
your therapist and mental health medicine manager be equal to "other specialty medical services". You say that 
you should be charged the $25 copayment and not an increased $40 copayment. 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 a $40 
copayment for each Medicare-covered individual session for outpatient mental health services provided by a 
mental health professional other than a psychiatrist. You have been asked to pay a $40 copayment for an outpatient mental health visit. An outpatient mental health 
visit falls 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 an outpatient mental health visit provided on February 18, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on June 2, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you only had this ultrasound 
because you were misdiagnosed so it should be covered. 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 $35 
copayment for each Medicare covered x-ray.  
 
You have been asked to pay $35 copayment 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 June 2, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
March 14, 2022. 
 
You asked the Plan to waive the copayment for the PT services. You say that you were not aware that you 
would owe $30 for each visit. 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 $30 
copayment for each physical therapy visit.  
 You have been asked to pay a $30 copayment for the PT services. The PT services fall within the Outpatient 
Rehabilitation 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 physical 
therapy (PT) services provided on March 14, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
March 4, 2022. 
 
You asked the Plan to waive the copayment for the PT services. You say that you were not aware that you 
would owe $30 for each visit. 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 $30 
copayment for each physical therapy visit.  
 You have been asked to pay a $30 copayment for the PT services. The PT services fall within the Outpatient 
Rehabilitation 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 physical 
therapy (PT) services provided on March 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient clinic visit provided on 
January 3, 2022. 
 
You asked the Plan to waive the copayment for an outpatient clinic visit. You say that you were not told by the 
provider a copayment was due at time of visit. You say that you disagree with the way the visit is being billed 
as an "outpatient hospital stay" and you were unaware of how expensive the visits were. 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 a $125 
copayment for all other outpatient services not provided in an ambulatory surgical center.  
 You have been asked to pay a $110.84 copayment for an outpatient clinic visit, which is less than the $125 
copayment. An outpatient clinic visit 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 an outpatient clinic visit provided on January 3, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
March 2, 2022. 
 
You asked the Plan to waive the copayment for the PT services. You say that you were not aware that you 
would owe $30 for each visit. 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 $30 
copayment for each physical therapy visit.  
 You have been asked to pay $22.61, which is less than the $30 copayment for the PT services. The PT services 
fall within the Outpatient Rehabilitation 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 physical therapy (PT) services provided on March 2, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on March 11, 
2021. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you were told there would be no 
charge. 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 $20 
copayment for Medicare covered physical therapy (in-person or virtual) visits.  
 
You have been asked to pay $20 copayment for physical therapy. Physical therapy falls within the Outpatient 
Rehabilitation 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 physical 
therapy provided on March 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an out-of-network specialist visit provided 
on March 28, 2022. 
 
You asked the Plan to waive the copayment for an out-of-network specialist visit. You say that you thought the 
provider was in-network because the provider shows up on the Plan's website. 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 a $55 
copayment for each out-of-network Medicare-covered specialist visit.  
 
You have been asked to pay a $55 copayment for an out-of-network specialist visit. An out-of-network 
specialist visit falls within the Physician/Practitioner Services, Including Doctors 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 an out-of-network specialist visit provided on 
March 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an urgent care visit and laboratory services 
provided on May 5, 2022. 
 
You asked the Plan to waive the copayments for an urgent care visit and laboratory services. You say that 
would like the $60 copayment to be waived. 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 a $10 
copayment for other Medicare-covered laboratory tests that are not FIT tests and a $50 copayment for each 
Medicare-covered urgent care facility visit.  
 
 
  You have been asked to pay $60 for an urgent care visit and laboratory services ($50 + $10 = $60). An urgent 
care visit falls within the Urgently Needed Services benefit category. Laboratory services 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 copayments for an urgent care visit and laboratory services provided on  
May 5, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
February 28, 2022. 
 
You asked the Plan to waive the copayment for the PT services. You say that you were not aware that you 
would owe $30 for each visit. 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 $30 
copayment for each physical therapy visit.  
 You have been asked to pay a $30 copayment for the PT services. The PT services fall within the Outpatient 
Rehabilitation 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 physical 
therapy (PT) services provided on February 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for surgical supplies provided on March 28, 
2022. 
 
You asked the Plan to waive the copayment for surgical supplies. You say that you were told there would be no 
charge. 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 $125 
copayment after the deductible is met for each outpatient surgery and/or services at an ambulatory surgical 
center or outpatient hospital facility.  
 
You have been asked to pay $125 copayment for surgical supplies. Surgical supplies 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 supplies 
provided on March 28, 2022.