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

 
We decided that the Plan does not have to waive the copayment for trigger point injections, and an injection 
using image guidance provided on April 03, 2023, to April 24, 2023. 
 
You asked the Plan to waive the copayment for trigger point injections, and an injection using image guidance. 
You say that you have never had to pay for these services before. The Plan denied your request. The Plan says 
this cost sharing was charged 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 $275 
copayment for Medicare-covered surgery or other services provided at an outpatient hospital. 
 
You have been asked to pay a $275 copayment for trigger point injections, and an injection using image guidance. This item/service falls within the Medicare-covered surgery or other services provided at an 
outpatient hospital 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. The total you owe is $527.09 ($252.09 + $275 = $527.09). The Plan is only holding you 
responsible for a $252.09 copayment for the service provided on April 3, 2023 because the allowed amount for 
this service is less than the $275 copayment. Therefore, we decided that the Plan does not have to waive the 
copayment for trigger point injections, and an injection using image guidance provided on April 03, 2023, to 
April 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care visit provided on December 
16, 2022. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that they did not provide any 
services and told you to go to the emergency room. The Plan denied your request. The Plan says this cost 
sharing was charged 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 $25 
copayment for urgently needed services. 
 
You have been asked to pay a $25 copayment for the urgent care visit. This item/service 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 the urgent 
care visit provided on December 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair with single power option 
(tilt). 
 
You asked the Plan to pre-approve a Group 2 power wheelchair with single power option. You say that the 
enrollee will benefit from the power tilt function to help facilitate a true functional weight shift for pressure 
relief. You also say that this frequency change in position will also help to decrease pain in the cervical/lumbar 
and lower extremity management and help with edema management. The Plan denied your request. The Plan 
says the enrollee does not have a medical need for the requested power option. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 2 power wheelchair with single power option 
may be covered when certain criteria have been met. 
 
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 Group 2 power wheelchair with single 
power option. Our reviewer says that the requested Group 2 power wheelchair with single power option is not 
medically necessary. Our physician reviewer found the provided documentation indicates the enrollee is 
functionally non-ambulatory and cannot use a cane or walker for assistance with mobility. The enrollee is 
unable to functionally propel a manual wheelchair due to lack of endurance and upper extremity weakness. The 
enrollee would benefit from a power wheelchair for mobility and performing daily activities. However, there is 
insufficient documentation indicating why the enrollee requires power tilt. The enrollee is not noted to have a 
history of skin breakdown or pressure wounds and is modified independent with transfers. Positioning for neck 
pain by itself is not a reason for power tilt for the power wheelchair. Therefore, the reviewer found that the 
requested Group 2 power wheelchair with tilt is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Group 2 power wheelchair with single power option have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair with single 
power option (tilt).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom glucose monitor. 
 
You asked the Plan to pre-approve a Dexcom glucose monitor. You say that you are having trouble with your 
current monitor. The Plan denied your request. The Plan says your current monitor was supplied less than five 
years ago and cannot be replaced. 
 
The Plan must follow Medicare rules. Medicare rules say that, in no case can the RUL of equipment be less 
than 5 years. The rules also say that replacement due to wear is not covered during the RUL of the equipment.  
 
The item being requested shows to be for replacement of an identical or nearly identical item, due to wear. The 
case file shows that the existing equipment is less than 5 years old. This means that replacement of this equipment due to wear is not covered at this time. Therefore, we decided that the Plan does not have to pre-
approve a Dexcom glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a LifeAlert system. 
 
You asked the Plan to pre-approve a LifeAlert system. You say that you need this device if you should faint or 
fall and not be able to get assistance. The Plan denied your request. The Plan says this item is not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that telephone alert systems (such as 
LifeAlert) are not covered.  
 
While a a LifeAlert may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a LifeAlert system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement flooring. 
 
You asked the Plan to pre-approve replacement flooring. You say that the enrollee is at a high risk of falling, 
and replacing the floors will help ensure her health. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. 
This item is available to the general public and would be helpful even to those who are not sick or injured. 
Therefore, we decided that the Plan does not have to pre-approve replacement flooring.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and wellness visit provided on July 18, 2023. 
 
You asked the Plan to pay for the office visit and wellness visit. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit and 
wellness visit provided on July 18, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) 
provided on June 22, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI). You say that you 
disagree with the cost share applied. The Plan denied your request. The Plan says this cost sharing was charged 
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 $200 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $200 copayment for a magnetic resonance imaging (MRI). This item/service 
falls within the outpatient diagnostic tests 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) provided on June 22, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on May 09, 2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that the provider does not who they will be 
seeing at the facility The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for skilled nursing facility 
provided on May 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99204 rendered on June 28, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documents do not support this level of care. 
 
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 99204 is "Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 45-59 
minutes of total time is spent on the date of the encounter." 
 
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 the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that the medical records do not 
support a moderate level of medical decision making, a comprehensive examination, or have the appropriate 
documentation of time spent. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99204 rendered on June 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on May 17, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory service 
provided on May 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Aspira OVA 1 assay test (81503) provided December 2, 
2022. 
 
You asked the Plan to pay for the laboratory service. You say that the enrollee has met medical necessity and 
the ordering physician is utilizing the results to customize the enrollee's treatment. The Plan denied your 
request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Per Local Coverage Determination (LCD) L38371 Multimarker 
Serum Tests Testing Related to Ovarian Cancer Testing as this is not a covered service. LCD L38371 is a non-coverage policy for all multi marker serum tests related to ovarian cancer testing. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided 
that the Plan does not have to pay for the Aspira OVA 1 assay test (81503) provided December 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 12013 billed for date of service April 11, 
2023. 
 You asked the Plan to pay for procedure code 12013. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 12013 is bundled into payment for code 26720. 
 
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 12013 
is a column II code to column I code 26720. 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 12013 billed for date of service April 11, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on June 8, 2023, billed with 
procedure codes Q9967 (5 units), 77012-59-RT, and A9575 (50 units). 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 codes Q9967 (5 units), 77012-59-RT, and A9575 (50 units) is 
low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml, computed tomography guidance 
for needle placement (eg, biopsy, aspiration, injection, localization device), radiological supervision, and 
injection, gadoterate meglumine, 0.1 ml. 
 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 the imaging services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that the medical record does not include 
sufficient documentation to verify the billed services. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the imaging services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for imaging services provided on June 8, 2023, billed with procedure codes 
Q9967 (5 units), 77012-59-RT, and A9575 (50 units).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6549 that 
were issued on May 2, 2023. 
 You asked the Plan to pay for the compression stockings. You say that these items were medically necessary. 
The Plan denied your request. The Plan says this item is non-covered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6549 that were issued on May 2, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on April 29, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you dont agree with the 
services because you were transferred from hospital to hospital. The Plan denied your request. The Plan says 
this cost sharing was charged 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 $275 
copayment for ambulance services. 
 
You have been asked to pay a $275 copayment for ambulance services. This item/service falls 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. However, since the allowed amount is less than the standard copayment, you only owe $250. 
Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided on 
April 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided from 
March 17, 2023, to April 6, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for a PCD have not 
been met. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. The rules also say that a PCD coded 
as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  
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, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided from March 17, 2023, to April 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on July 05, 2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you say that you were concerned 
about being charged $70. The Plan denied your request. The Plan says this cost sharing was charged 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 $35 
copayment for hearing services. 
 
You have been asked to pay a $35 copayment for an office visit. This item/service falls within the hearing 
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 office visit provided on 
July 05, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance transportation provided on 
May 06, 2023. 
 
You asked the Plan to waive the copayment for an ambulance transportation. You say that you were told that 
you would not be charged for this service. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $220 
copayment for ambulance services. 
 
You have been asked to pay a $220 copayment for an ambulance transportation. This item/service falls 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 an 
ambulance transportation provided on May 06, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on January 
01, 2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says this cost sharing was charged 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 $220 
copayment for ambulance services. 
 
You have been asked to pay a $220 copayment for ambulance services. This item/service falls 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 ambulance services 
provided on January 01, 2023.