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

 
We decided that the Plan does not have to pay for procedure code 81161 billed for date of service November 
29, 2021. 
 
You asked the Plan to pay for the services provided. You say that the treatment sought was medically necessary 
to treat the enrollee. The Plan denied your request. The Plan says an appropriate modifier was not billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
In this case, we have confirmed that code 81161 is a column II code to column I code 81413. 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 81161 
billed for date of service November 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70460 billed for date of service February 28, 
2022. 
 You asked the Plan to pay for the testing services. You say that this code is not bundled with any other 
procedure. The Plan denied your request. The Plan says an appropriate modifier was not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
In this case, we have confirmed that code 70460 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 70460 
billed for date of service February 28, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance on March 16, 2022. 
 
You asked the Plan to waive the copayment for ambulance. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing the enrollee is 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $265 copayment per date of service regardless of the number of trips for ground ambulance.  
Covered ambulance services include fixed wing, rotary wing, and ground ambulance services, to the nearest 
appropriate facility that can provide care only if they are furnished to a member whose medical condition is 
such that other means of transportation could endanger the person's health or if authorized by the plan. 
 
 
 
 
 The enrollee has been asked to pay a $265 copayment for ambulance. Ambulance falls within the Ambulance 
services benefit category. 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 copayment for ambulance on March 
16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory work provided on March 22, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory work. You say that you would like the laboratory clinicals to be 
reviewed and the claim to be reprocessed and paid. 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 
laboratory work. We found no exception that would require the Plan to pay for the laboratory work. The record 
shows CPT code 36415 was billed which means the provider had the opportunity to confirm insurance 
coverage and authorization. Therefore, we decided that the Plan does not have to pay for the laboratory work 
provided on March 22, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nail debridement services (G0127, 11720) provided on 
April 14, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the debridement services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim processed correctly. 
 
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 referring provider was not a network 
provider with the Plan either. 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 nail debridement services (G0127, 11720) provided on April 14, 2022, by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the office visit (99214) provided on April 28, 
2022. 
 
You asked the Plan to reimburse you for the physician service. You say that your doctor is Medicare qualified 
as they used to be in-network for your plan. You say that they chose to opt out of all insurance. You also say 
that you have paid in full and expect to be reimbursed 50% of the Medicare rate. The Plan denied your request. 
The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be 
made to a provider that has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for 
the office visit (99214) provided on April 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost-sharing for diagnostic services and injections 
provided on March 15, 2022. 
 
You asked the Plan to reduce the cost-sharing for diagnostic services and injections. You say that you feel the 
cost shares are too high and you can't afford them. You say that you understood you only needed to pay $50 
copayment for a stress test. The Plan denied your request. The Plan says The cost-sharing 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 $50 
copayment for Medicare-covered non-radiological diagnostic services, a $185 copayment for radiological 
diagnostic services, 20% coinsurance for each Medicare-covered medical supply and 20% coinsurance for all 
other Medicare-covered Part B drugs. 
 
You have been asked to pay a total cost-share amount of $362.76 for diagnostic services and injection. 
 
Service Allowed Amount Cost Per Contract Member Liability 
Myocardial Perfusion Imaging $512.11 $185 $185 
Regadenoson Injection $238.80 20% $47.76 
Stress Test $68.27 $50 $50 
Medical Supply $400 20% $80 
TOTAL:   $362.76 
 
The myocardial perfusion imaging, stress test and medical supply fall within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies benefit category. The injection falls within the Medicare Part B 
Prescription Drugs benefit category. 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 cost-sharing for diagnostic 
services and injections provided on March 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs this level of care. The Plan denied 
your request. The Plan says admission is not medically necessary and the enrollee does not meet criteria for 
admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 
 Our physician reviewer found the enrollee was admitted for surgical repair of a hip fracture after a fall. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the enrollee has a need for 
physical or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hospital outpatient clinic visit for 
assessment and wound care services provided from February 21, 2022, to February 28, 2022. 
 
You asked the Plan to waive the copayment for the outpatient facility visit and wound care. You say that you 
went to a wellness facility and not a hospital. 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 an outpatient hospital visit.  
 
You have been asked to pay a $295 copayment for an outpatient hospital visit and wound care. The outpatient 
clinic visit and wound care 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 the hospital outpatient clinic visit for assessment and wound care services provided from 
February 21, 2022, to February 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for colonoscopy on March 15, 2022. 
 
You asked the Plan to waive the copayment for colonoscopy. 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 $340 
copayment for each Medicare-covered visit to an ambulatory surgical center or outpatient hospital facility. If 
you are having surgery in a hospital facility, you should check with your provider about whether you will be an 
impatient or outpatient. Unless the provider writes an order to admit you as an impatient to the hospital, you are 
an outpatient and pay the cost sharing amounts for outpatient surgery. Even if you stay in the hospital 
overnight, you might still be considered an outpatient.  
 
 
  
You have been asked to pay a $340 copayment for colonoscopy. 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 colonoscopy on March 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on April 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you should not be responsible since the problem 
was not addressed on the first visit. 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 Plan's 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 date of service April 4, 2022. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on April 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom fabricated abutment-includes placement (D6057) 
and the implant supported porcelain/ceramic crown (D6065) provided on May 31, 2022. 
 
You asked the Plan to pay for these dental items. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these dental items are not covered under your 
contractual policy. 
 
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, the items provided are not among those 
covered under this benefit.  Therefore, we decided that the Plan does not have to pay for the custom fabricated abutment-includes 
placement (D6057) and the implant supported porcelain/ceramic crown (D6065) provided on May 31, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory (lab) services provided on July 29, 2021. 
 
You asked the Plan to pay for lab services. The Plan denied your request. The Plan says original Medicare is 
responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for laboratory (lab) services provided on July 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
February 4, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that that you were taken 
against your will by the ambulance company. 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 $100 
copayment per trip.  
 
You have been asked to pay a $100 copayment for ambulance services. The ambulance services fall 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 the ambulance 
services provided on February 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment and coinsurance for an orthovisc injection 
provided on April 12, 2022. 
 
You asked the Plan to reduce the copayment and coinsurance for the injection. You say that you were informed 
that each shot would only be $50. The Plan denied your request. The Plan says the correct copayment and 
coinsurance were applied. 
 
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 $50 
copayment for specialist services.  
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for Part B drugs. 
 
You have been asked to pay a $50 copayment for the specialist services. The specialist services fall within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. You have also been asked to 
pay $29.55 for the orthovisc drug, which is 20% of the allowed amount ($147.75 allowed amount x 20% 
coinsurance = $29.55). The orthovisc drug falls within the Medicare Part B Prescription Drugs benefit 
category. The total cost for the injection is $79.55. 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 and 
coinsurance for an orthovisc injection provided on April 12, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on August 9, 
2021. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you should not be responsible 
for this cost share. The Plan denied your request. The Plan says the cost share 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 a $20 
copayment for Medicare-covered physical therapy visits.  
 
You have been asked to pay $20 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 August 9, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve special supplemental benefits for the chronically ill.

You asked the Plan to pre-approve special supplemental benefits for the chronically ill. You say that this is medically necessary for your condition. The Plan denied your request. The Plan says that you do not qualify for these benefits.

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. In this case, the Plan has denied special supplemental benefits for the chronically ill stating that your provider submitted an attestation stating that these were not necessary. This attestation was not included in the case file. We requested additional information from the Plan that would support your request for these benefits indicating we needed medical records to confirm whether you would qualify for the program. A response to our request for information was not returned. Therefore, we decided that the Plan has to pre-approve special supplemental benefits for the chronically ill. 

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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that the requested Injectafer is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for the requested Injectafer. 
 
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 Injectafer. Our reviewer says that the 
enrollee does not meet criteria for the requested Injectafer. Our physician reviewer found the record indicates 
that the enrollee has iron deficiency anemia in the setting of stage IV chronic kidney disease. The record 
provided does not indicate that oral supplementation has been tried and the enrollee has demonstrated 
significant gastrointestinal distress whereas compliance with an oral regimen is no longer feasible. The 
elements of the coverage criteria are not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.