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 and garments (E0652, 
E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and garments. You say that the requested 
items are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
Medicare guidelines as there is no trial of at least four weeks of regular, daily, multiple-hour home usage of the 
E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and 
who regularly and successfully uses the appliance. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
and garments (E0652, E0667).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for x-ray on March 08, 2022. 
 
You asked the Plan to waive the coinsurance for x-ray. You say that you want to appeal the amount being 
charged. 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 35% 
coinsurance for each out-of-network Medicare-covered X-ray. Covered services include but are not limited to 
x-rays. The provider billed in the amount of $116 and the allowed amount is $8.28. $8.28 x 35% = $2.90. 
Therefore, results in the total cost sharing amount of $2.90. 
 
You have been asked to pay a 35% coinsurance for x-ray. X-rays 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 coinsurance for 
x-ray on March 08, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder. 
 
You asked the Plan to pre-approve an implantable loop recorder. You say that the requested implantable loop 
recorder is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria 
for the requested implantable loop recorder. 
 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 an implantable loop recorder. Our 
reviewer says that the enrollee does not meet criteria for the requested implantable loop recorder. Our physician 
reviewer found while the enrollee has a history of atrial fibrillation, there is no documentation provided to 
suggest a history of unexplained syncope, or any other apparent indication for an ILR. In summary, there is 
insufficient documentation to support the medical necessity for insertion of an ILR in this enrollees clinical 
management. 
 
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 implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantable loop recorder.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an epidural injection provided on April 22, 
2022. 
 
You asked the Plan to waive the copayment for an epidural injection. You say that you should not have to pay 
this copayment, because the procedure did not help or bring enough relief. The Plan denied your request. The 
Plan says the copayment that was applied was 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 $200 
copayment for outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility.  
 
You have been asked to pay a $200 copayment for an epidural injection. An epidural injection 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 epidural injection provided on April 22, 
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 April 19, 
2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that this is your current primary care 
provider and should not have a copayment. The Plan denied your request. The Plan says the copayment that 
was applied was correct. This provider is still considered a specialist. 
 
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 Physician/Practitioner services, including doctor's office visits.  
 
You have been asked to pay a $35 copayment for a specialist visit. a specialist 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 visit provided on April 19, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service April 28, 
2022. 
 
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 code 76705 is bundled into payment for 
code 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 April 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on November 
12, 2021. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you were very sick with 
Covid-19 over the weekend and your primary care provider was unable to see you. 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 covered office visit to other providers for urgently needed services.  
 
You have been asked to pay a $40 copayment for an urgent care visit. An urgent care visit 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 waive the copayment for an urgent 
care visit provided on November 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional periapical x-ray (D0230) provided January 17, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that you would have x-rays 
or that they would not be covered. The Plan denied your request. The Plan says your benefit for the requested 
item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on the same date of service, January 17, 
2022. Therefore, we decided that the Plan does not have to pay for the additional periapical x-ray (D0230) 
provided January 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device and appliances to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the requested items are available from an 
in-network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compression device and appliances to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an endoscopy and diagnostic colonoscopy 
performed from April 7, 2022, to April 14, 2022. 
 
You asked the Plan to waive the copayments for the endoscopy and colonoscopy. You say that the services are 
diagnostic tests and should be covered. 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 $295 
copayment for each ambulatory surgical center visit.  
 
You have been asked to pay a $295 copayment each for the endoscopy and colonoscopy, for a total of $590. 
The endoscopy and colonoscopy fall within the Outpatient Surgery, Including Services Provided at Hospital 
Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayments for an endoscopy and diagnostic colonoscopy performed from April 7, 2022, to April 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on May 20, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 
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 the physician services provided on May 20, 2022, 
by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service April 1, 
2022. 
 
You asked the Plan to pay for procedure code 70544. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70544 is bundled into payment for 
code 70551. 
 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 70544 
is a column II code to column I code 70551. 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 70544 billed for date of service April 1, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
from March 1, 2022, to March 4, 2022. 
 
You asked the Plan to waive the copayment for the SNF care. You say that you thought skilled nursing was 
covered 100%. 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 $0 per 
day for days 1-20, $188 per day for days 21-52, and $0 per day for additional days for each benefit period. 
 
Dates of Service Benefit Days Copayment 
February 10, 2022  March 1, 2022 1-20 $0/day 
March 2, 2022  March 4, 2022 21-23 $188/day 
Total:  $564 The file shows that you were in the nursing facility from February 10, 2022, to March 4, 2022. You have been 
asked to pay $188 per day for days 23 for the SNF care. The total for your stay is $564. The SNF care falls 
within the Skilled Nursing Facility (SNF) 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 skilled nursing facility (SNF) care provided from March 1, 2022, to March 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME provided from May 21, 2022, to 
June 9, 2022. 
 
You asked the Plan to waive the coinsurance for DME. You say that your copayment has been $0 for the past 
three years. You say that your share should not have changed as there were no changes with your plan. The 
Plan denied your request. The Plan says the coinsurance 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% 
coinsurance for each Medicare-covered durable medical equipment item.  
 
 
  You have been asked to pay $30.60, which is 20% of the allowed amount for the DME.  
 
Service date(s) Service Number of 
days 
Allowed Amount Cost per 
Contract 
Member 
Responsibility 
May 21, 2022 to 
June 9, 2022 
Ost skin Barrier 
(A4385) 
20 $7.64/day 20% $1.53/day  
($1.53 x 20 days) 
      
Total      $30.60 
 
 
DME falls within the Durable Medical Equipment (DME) and Related 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 coinsurance for DME provided from May 21, 2022, to June 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the therapy sessions provided from 
February 16, 2022, to March 3, 2022. 
 
You asked the Plan to waive the copayments for the therapy sessions. You say that you were told by your 
social worker that this service would have no cost. The Plan denied your request. The Plan says the copayments 
applied are 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 $25 
copayment for each Medicare-covered individual therapy session.  
 
You have been asked to pay a total of $75, a $25 copayment for each therapy session ($25 copayment x 3 
sessions = $75). Therapy sessions fall within the Outpatient Mental Health Care benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayments for the therapy sessions provided from February 16, 2022, to March 3, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor and segmental pneumatic 
device (E0651, E0667) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the pneumatic compressor and segmental pneumatic device. You say that 
the items should be covered as you disagree with the denial. The Plan denied your request. The Plan says the 
items denied correctly as they are non-emergent and can be provided in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compressor and segmental pneumatic device (E0651, E0667) to be provided by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for primary care telehealth services provided 
on April 12, 2022. 
 
You asked the Plan to waive the copayment for the primary care telehealth services. You say that the call did 
not last 5 minutes and the provider was not able to help you. 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 $10 
copayment for primary care telehealth services.  
 
You have been asked to pay a $10 copayment for the primary care telehealth services. The primary care 
telehealth services fall within the Telehealth 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 primary care telehealth services provided on April 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab work provided on April 8, 2022. 
 
You asked the Plan to waive the copayment for lab work. You say that you saw your provider the same day 
you had these labs done, therefore you feel you should not have to pay a second copayment. The Plan denied 
your request. The Plan says the copayment that was applied was 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.  
 
You have been asked to pay a $10 copayment for lab work. Lab work 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 waive the copayment 
for lab work provided on April 8, 2022.