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

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the 
leg joint provided on September 16, 2021. 
 
You asked the Plan to waive the copayment for an MRI. You say that you were unaware there was a charge of 
$350 for the MRI. You also say no one told you about the copayment when you had the test done. 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 $350 
copayment for in-network diagnostic radiology, including MRIs.  
 
You have been asked to pay a $350 copayment for an MRI. An MRI 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 a magnetic resonance imaging (MRI) of the leg joint provided on September 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (75710, 75736) provided on September 13, 
2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are 
included in another 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, we have confirmed that code 75710 
and 75736 is a column II code to column I code 37243. Based on the claim submitted, Medicare billing criteria 
have not been met. Therefore, we decided that the Plan does not have to pay for the services (75710, 75736) 
provided on September 13, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an abdominal ultrasound (76705) provided on December 2, 
2021. 
 You asked the Plan to pay for an abdominal ultrasound. You say that you have provided records to support the 
level of service. The Plan denied your request. The Plan says rules for payment have not been met because the 
service at issue is included in another billed code. 
 
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 an abdominal ultrasound (76705) provided on December 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for intravenous (IV) infusion provided on 
October 22, 2021, and October 29, 2021. 
 
You asked the Plan to waive the copayments for IV infusion. You say that your doctor ordered an IV iron 
infusion. 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 $300 
copayment for in-network outpatient surgery or other services, including therapeutic services at an outpatient 
hospital.  
 
 You have been asked to pay a total of $222.97, which is less than the $300 copayment for IV infusion provided 
on October 22, 2021 ($186.34 copayment + $36.63 copayment = $222.97). You have also been asked to pay a 
total of $222.97, which is less than the $300 copayment for IV infusion provided on October 29, 2021 ($186.34 
copayment + $36.63 copayment = $222.97). You have been asked to pay a total of $445.94 for IV infusions 
($222.97 copayment + $222.97 copayment = $445.94). An IV infusion falls within the 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 intravenous (IV) infusion provided on October 
22, 2021, and October 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vertiplex superion device (22869, 22870, 01992). 
 
You asked the Plan to pre-approve a vertiplex superion device. You say that the service at issue is medically 
necessary. The Plan denied your request. The Plan says Medicare does not cover unproven and not medically 
necessary procedures due to insufficient evidence of efficacy. 
 
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 a vertiplex superion device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is an experimental procedure and more research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a vertiplex superion device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a vertiplex superion device (22869, 22870, 01992).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an ankle orthosis boot provided on 
September 15, 2021. 
 
You asked the Plan to waive the coinsurance for an ankle orthosis boot. You say that you stopped using the 
boot because it was digging into your skin. You also say that you tried returning the boot and they would not 
accept it. 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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay $115.15, which is 20% of the allowed amount for an ankle orthosis boot ($575.76 
allowed amount x 20% coinsurance = $115.15). An ankle orthosis boot 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 an ankle orthosis boot provided on September 
15, 2021.  
 
Your complaint about your boot not fitting properly and the amount of time your foot doctor spent with you is 
not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by 
the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and the copayment for an echocardiography, 
transthoracic, real-time with image documentation (93306) and an injection, perflutren lipid microspheres 
(Q9957) provided on September 9, 2021. 
 You asked the Plan to waive the deductible and the copayment for an echocardiography, transthoracic, real-
time with image documentation and an injection, perflutren lipid microspheres. You say that you had this 
procedure previously before in September of 2021, and there was no out-of-pocket cost when you went. You 
also say that no money amount or copayment was mentioned, which in your mind meant that it was not going 
to cost anything. You also say that you do not think you should have to pay this, and you are retired and on a 
fixed income. The Plan denied your request. The Plan says you were 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 $395 
deductible that applies to the items and services specifically listed in the Plan contract, which includes 
outpatient hospital services. Your contract with the Plan also says that you must pay a $395 copayment for each 
Medicare-covered outpatient hospital visit after you meet your $395. 
 
You have been asked to pay $357.62 towards the deductible for an echocardiography, transthoracic, real-time 
with image documentation and an injection, perflutren lipid microspheres. You also have been asked to pay a 
and a $395 copayment for an echocardiography, transthoracic, real-time with image documentation and an 
injection, perflutren lipid microspheres. An echocardiography, transthoracic, real-time with image 
documentation and an injection, perflutren lipid microspheres falls within the outpatient hospital services 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $395 
deductible, which applies to outpatient hospital services. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Please note that this deductible is also a contractual obligation that had not 
been met at the time echocardiography, transthoracic, real-time with image documentation and an injection, 
perflutren lipid microspheres was received on September 9, 2021 Therefore, we decided that the Plan does not 
have to waive the deductible and the copayment for an echocardiography, transthoracic, real-time with image 
documentation (93306) and an injection, perflutren lipid microspheres (Q9957) provided on September 9, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cochlear implant evaluation procedures (92604, 92626, 
92652) provided on November 9, 2021. 
 
You asked the Plan to pay for cochlear implant evaluation procedures. 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 hearing 
services have not been met. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when services are obtained from a network provider.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of cochlear implant evaluation procedures have not been met. Specifically, the services at issue in this 
case were not obtained from a network provider. Therefore, we decided that the Plan does not have to pay for 
cochlear implant evaluation procedures (92604, 92626, 92652) provided on November 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance transportation for (A0428) 
provided on May 11, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. 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 $250 
copayment for Ambulance Services.  
 
You have been asked to pay a $250 copayment for ambulance transportation. 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 ambulance transportation for (A0428) provided on May 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on September 22, 2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this test is experimental. 
 
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 pay for the Guardant360 testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support that the enrollee in this case is untreated for the 
primary cancer being tested, or is not responding to treatment. The documentation does not show if the enrollee 
has decided to seek further treatment. 
 
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 Guardant360 testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the Guardant360 testing provided on September 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
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 at the current level of function, the enrollee's rehab can be safely provided at a lower 
intensity and alternate setting such as a skilled nursing facility.  
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 18, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing provided on June 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 3, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on June 3, 2021.
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 
October 26, 2021. 
 
You asked the Plan to waive the copayment for an outpatient clinic visit. You say that you are very unhappy 
about being charged an extra $100. You also say you were seen at your oncologist's office not at the 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 $475 
copayment for a non-surgical visit at an outpatient clinic.  
 
The record shows your visit was at an outpatient facility. You have been asked to pay the allowed amount of 
$128.35, which is less than the $475 copayment for an outpatient clinic visit. An outpatient clinic visit falls 
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 an outpatient clinic visit provided on October 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs LTACH care. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and is 
currently unstable for transfer to 
an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where he is 
currently receiving care. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic physical therapy services provided to the 
enrollee from October 2, 2021, to November 10, 2021. 
 
You asked the Plan to pay for the services. You say that this was the only thing to help the enrollee's pain. The 
Plan denied your request. The Plan says the request is not a covered benefit because Medicare does not cover 
non-manipulative services provided by chiropractors. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic physical therapy services provided to the enrollee from October 
2, 2021, to November 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan of arterial inflow and venous outflow 
services (93976) provided on October 20, 2021. 
 
You asked the Plan to pay for the duplex scan services. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says this claim has not been billed with 
an appropriate modifier as required by Medicare.  
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 93976 
is a column II code to column I code 76856. 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 the duplex scan of arterial inflow and venous outflow services 
(93976) provided on October 20, 2021.