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

 
We decided that the Plan does not have to waive the copayment and coinsurance for a specialist office visit and 
romosozumab injection provided on September 16, 2021. 
 
You asked the Plan to waive the copayment and coinsurance for the specialist visit and injection. You say that 
you do not understand why the enrollee's cost share went from $0 to $391 per month. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $20 copayment for each specialty physician visit. 
 
The enrollees contract with the Plan also clearly says that enrollees must pay a 20% coinsurance for Part B 
drugs. The enrollee has been asked to pay a $20 copayment for the specialist visit. The specialist visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. The enrollee has also been 
asked to pay $391.02 for the injection, which is 20% of the allowed amount ($1,955.10 allowed amount x 20% 
coinsurance = $391.02). The injection falls within the Medicare Part B Prescription Drugs benefit category. 
The total for the visit is $411.02. 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 and 
coinsurance for a specialist office visit and romosozumab injection provided on September 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an automatic external defibrillator (AED) 
vest provided on November 14, 2021. 
 
You asked the Plan to waive the coinsurance for the AED vest. You say that you were informed that insurance 
would cover the costs. The Plan denied your request. The Plan says the correct coinsurance was 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 20% 
coinsurance for durable medical equipment (DME) items.  
 
You have been asked to pay $586.29, which is 20% of the allowed amount for the AED vest ($2,931.45 
allowed amount x 20% coinsurance = $586.29). The AED vest 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 
automatic external defibrillator (AED) vest provided on November 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
December 7, 2021. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you feel you should not 
be responsible for this cost share amount, and you would like the Plan to reconsider your request. The Plan 
denied your request. The Plan says you received ambulance services on the date of service at issue in this 
appeal. The Plan says that the correct copayment has applied per your contract with the Plan. 
 
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 $225 
copayment for Ambulance Services.  
 
You have been asked to pay a $225 copayment for the 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 December 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle 
Libre continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for presbyopia correcting function of intraocular lens (code V2788) 
provided on January 10, 2022. 
 
You asked the Plan to pay for presbyopia correcting function of intraocular lens. You say that you called the 
Plan and you were told this service would be covered minus a $295 deductible. The Plan denied your request. 
The Plan says that the mandatory supplemental vision plan only covers in network providers. 
 
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. Specifically, the Plan has not provided consistent information with regard to the 
network status of the rendering provider. The Plan has not provided the rule showing why this service would 
not be covered as this service is not a routine vision benefit. Therefore, we decided that the Plan has to pay for 
presbyopia correcting function of intraocular lens (code V2788) provided on January 10, 2022.  
 
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 pay for the adjustment of gastric band diameter via subcutaneous 
port by injection or aspiration of saline (S2083) provided on March 11, 2022 by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the gastric band adjustment. You say that please review the claim with the 
attached medical records and process the claim for payment. The Plan denied your request. The Plan says enrollees must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 
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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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. Also, S codes are temporary codes which are used to report drugs, services and supplies 
for which there are no national codes. Private insurers for claim processing, policies or programs primarily use 
these codes. These codes are not payable by Original Medicare (OM).  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 adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline (S2083) 
provided on March 11, 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 wound debridement services (11045, 11042) provided on 
March 3, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound care services. You say that due to the enrollee's medical condition 
your physician provided care in good will without requesting an authorization to avoid delay in care. The Plan 
denied your request. The Plan says enrollees must receive their medical services from an in-network provider 
with the exception being urgent or emergent services. Non-emergent services with non-contracted providers 
require prior authorization before services being rendered. 
 
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 wound debridement services (11045, 11042) 
provided on March 3, 2022 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pneumatic compression device (E0652) and 
segmental pneumatic appliance (E0656, E0667) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve compression device. You say that you ask for reversal of the denial as the 
attached documentation speaks to the enrollee's clinical presentation, failure of conservative treatments and the 
need for the prescribed Flexitouch. The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
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 
the pneumatic compression device (E0652) and segmental pneumatic appliance (E0656, E0667) to be provided 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the collection from an implanted port (code 
36591) you received at an outpatient hospital facility on March 30, 2022. 
 
You asked the Plan to waive the copayment for code 36591. You say that this service should not be considered 
a lab service and the copayment is a large sum for you. The Plan denied your request. The Plan says you were 
charged this copayment 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 $50 
copayment for lab services in an outpatient hospital facility.  
 
You have been asked to pay a $50 copayment for code 36591. Medicare considers code 36591 to be a lab 
service, so code 36591 falls within the lab services in an outpatient hospital facility 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 collection from an implanted port (code 36591) you 
received at an outpatient hospital facility on March 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing related to end-stage renal disease (ESRD) 
provided on December 6, 2021. 
 
You asked the Plan to pay for the ESRD-related testing. You say that there is no contractual agreement in place 
that indicates that these codes are included in payment for dialysis. The Plan denied your request. The Plan 
says Medicare rules do not allow separate payment for ESRD lab testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab testing related to end-stage renal disease (ESRD) provided on December 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chemotherapy administration services coded 96413 provided 
on August 26, 2021. 
 
You asked the Plan to pay for chemotherapy administration services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says the documentation does 
not support payment for this code as 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, the CPT Code Manual definition of code 96413 is chemotherapy administration, intravenous 
infusion technique; up to 1 hour, single or initial substance/drug. 
 
We asked our coder 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 chemotherapy administration services. Our reviewer says 
that the documentation does not support payment for the CPT code billed. Our reviewer found that the procedure reports describes Vyepti infusion for migraines. Chemotherapy administration is the incorrect code 
for the service documented. There is a more appropriate code to report for this service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of chemotherapy administration services have not been met. Therefore, we decided 
that the Plan does not have to pay for chemotherapy administration services coded 96413 provided on August 
26, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an endoscopy performed on January 14, 
2022. 
 
You asked the Plan to waive the deductible for the endoscopy. You say that you were informed your 
responsibility would only be the $275 copayment. The Plan denied your request. The Plan says the correct 
deductible and copayment were applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $1,000 deductible which applies to certain items and services. 
 
Your contract with the Plan also clearly says that you must pay a $275 copayment for each surgery or service 
after the deductible is met. 
 
The endoscopy falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient 
Facilities and Ambulatory Surgical Centers benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $1,000 deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not been met at the time the endoscopy was received on January 14, 
2022.  
 
The file shows that at the time the claim was processed, you had a total of $543.46 remaining to meet your 
deductible. Once the deductible was met, the $275 copayment is applied to the remaining balance, for a total 
responsibility of $818.46. This means you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the deductible for an endoscopy performed on 
January 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided February 19, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that this was a reasonable use of ambulance 
services. The Plan denied your request. The Plan says this service is not covered when there is no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 The ambulance company did not provide transport services on February 19, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided February 19, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the individual psychotherapy session (90837) provided on 
February 14, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy services. You say that you chose to see this provider for services 
because you were assured that she accepted your insurance. You would not have moved forward with services 
had you known coverage would be denied. The Plan denied your request. The Plan says enrollees must receive 
their medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
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 individual psychotherapy session (90837) 
provided on February 14, 2022 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an endoscopy performed on March 7, 
2022. 
 
You asked the Plan to reduce the copayment for the endoscopy. You say that this was done in the physician's 
office and should only have a $15 copayment. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment per visit for surgery or services at an outpatient hospital or ambulatory surgical center.  
 
You have been asked to pay a $50 copayment or the endoscopy. The endoscopy falls within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. Please note that any physician charges would be in addition to the procedure copayment. 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 endoscopy performed on March 7, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vascepa. 
 
You asked the Plan to pre-approve Vascepa. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Vascepa.  
 
Benefits for Vascepa may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan provided on April 4, 2022. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you should not have this copayment. 
You thought it would be part of the urgent care visit. The Plan denied your request. The Plan says the 
copayment 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 $325 
copayment for Medicare-covered diagnostic radiology services.  
 
You have been asked to pay the allowed amount of $204.95 which is less than the $325 copayment for a CT 
scan. A CT scan falls within the Medicare-Covered Diagnostic Radiology 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 a CT scan provided on April 4, 2022.