Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the arthrocentesis and the triamcinolone 
injection provided on January 16, 2023. 
 
You asked the Plan to waive the cost share for the arthrocentesis and the injection. You say that these injections 
have been covered in the past. 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 $30 
copayment for in-network provider and professional services provided at a specialist's office. Your contract 
with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B covered drugs. 
 
You have been asked to pay a $30 copayment for the arthrocentesis. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and supplies benefit category. You have also been asked to 
pay $1.74, which is 20% coinsurance of the allowed amount for the injection ($8.72 allowed amount x 20% = 
$1.74). This item/service falls within the Medicare Part B prescription drugs benefit category. You have been 
asked to pay a total of $31.74 ($30 copayment + $1.74 coinsurance = $31.74). 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 cost share for the arthrocentesis and the triamcinolone injection provided on January 16, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room service provided on 
December 29, 2022. 
 
You asked the Plan to waive the copayment for the emergency room service. You say that you did not see an 
actual doctor. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for the emergency room service. This item/service falls within 
the emergency care benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room 
service provided on December 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the specialist office visit provided on June 
15, 2022, and the eye surgery provided on September 6, 2022. 
 
You asked the Plan to waive the cost share for the specialist office visit and the eye surgery. You say that the 
service should be reprocessed with a $0 cost share. 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 $45 
copayment for in-network physician specialist services. Your contract with the Plan also clearly says that you 
must pay 45% coinsurance for each out-of-network Medicare-covered outpatient surgery at an ambulatory 
surgical center. 
 
You have been asked to pay a $45 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category You have also been asked to 
pay $138.10, which is 45% coinsurance of the allowed amount for the eye surgery ($306.90 allowed amount x 
45% = $138.10).  This item/service falls within the outpatient surgery, including services provided at 
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 cost share for the specialist 
office visit provided on June 15, 2022, and the eye surgery provided on September 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on January 03, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that the CT scan is 
medically necessary and should be approved. 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 $350 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $350 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic test 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 the enrollee owes is $97.56, which is less than the standard $350 
copayment for an out-of-network CT scan. Therefore, we decided that the Plan does not have to waive the 
copayment for a computed tomography (CT) scan provided on January 03, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral waterjet ablation of the prostate. 
 
You asked the Plan to pre-approve transurethral waterjet ablation of the prostate. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 transurethral waterjet ablation of the 
prostate. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found transurethral waterjet ablation of the prostate is not 
medically reasonable and necessary in this case. The most recent AUA guidelines state that Robotic waterjet 
treatment (RWT) may be offered as a treatment option to patients with lower urinary tract symptoms/benign prostatic hyperplasia (LUTS/BPH) provided prostate volume 30-80cc. The records show that the prostate size 
in this case is 124.6 mL. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transurethral waterjet ablation of the prostate have not been met. Therefore, we 
decided that the Plan does not have to pre-approve transurethral waterjet ablation of the prostate.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
January 31, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that this should be 
considered a follow-up to a previous surgery. 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 $45 
copayment for in-network specialist physician/practitioner services. 
 
You have been asked to pay a $45 copayment for the specialist office visit. This item/service falls within the 
in-network specialist physician/practitioner 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. The records show the global period for your previous surgery 
ended on January 29, 2023. Therefore, we decided that the Plan does not have to waive the copayment for the 
specialist office visit provided on January 31, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the lesion removal procedure provided on 
January 12, 2023. 
 
You asked the Plan to reduce the copayment for the lesion removal procedure. You say that you had the same 
procedure at the same location and you were charged less. 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 $350 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $350 copayment for the lesion removal procedure. This item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities 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 $204.67. Therefore, we decided that the Plan does not have to 
reduce the copayment for the lesion removal procedure provided on January 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on September 
06, 2022. 
 
You asked the Plan to pay for an office visit and related services. You say that these services were medically 
necessary. 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 an office visit and 
related services provided on September 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapy services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve therapy services. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 in Chapter 3). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of the plan's network) will not be covered. This means that the 
enrollee will have to pay the provider in full for the services furnished. 
 
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 
therapy services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic compression device to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve pneumatic compression device. You say that you are requesting 
reconsideration asking for review of coverage. The Plan denied your request. The Plan says the enrollee must 
receive their care from a network provider (for more information about this, see Section 2 in Chapter 3). In 
most cases, care the enrollee receives from an out-of-network provider (a provider who is not part of the plan's 
network) will not be covered. This means that the enrollee will have to pay the provider in full for the services 
furnished. 
 
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 
pneumatic compression device to be provided by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital inpatient care services provided on February 13, 
2023. 
 You asked the Plan to pay for the hospital inpatient care 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 12, 2023. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the hospital inpatient 
care services provided on February 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001). 
 
You asked the Plan to pre-approve ultrasound guided radiation therapy. You say that you disagree with the 
denial. The Plan denied your request. The Plan says your doctor requested coverage for a special type of 
radiation treatment to treat your skin cancer. There is not enough evidence that this type of radiation therapy 
guidance is needed or effective for your skin cancer. 
 
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 ultrasound guided radiation therapy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found usually, IGRT is used when critical structures are abutting or in close 
proximity to the target that is being treated to high doses. This situation does not apply to you for which the 
target lesion can be seen on the skin to assist in daily set up. When treating skin cancers, there is generally not a 
need for IGRT unless deep structures are being treated. Certainly, using ultrasound on a daily basis is not 
unreasonable to offer but not necessary. The device itself is FDA approved for use with ultrasound though that 
in and of itself does not mean that daily imaging is necessary but simply that the device was designed to 
incorporate this functionality. Therefore, to bill for daily simple simulations (77280 - also requested in this 
case) and/or IGRT for a technology for which need has not been established by published data or supported by 
consensus guidelines (many of which recommend against treatment with these devices in general) is not 
necessary. The decision is unfavorable as billing for daily IGRT which would not be furnished in accordance 
with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasound guided radiation therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for each cochlear implant device provided on 
August 11, 2022, to November 10, 2022. 
 
You asked the Plan to reduce the coinsurance for each cochlear implant device. You say that you are being 
overcharged. 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 20% 
coinsurance for prosthetic devices and related supplies. 
 
You have been asked to pay 20% coinsurance for each cochlear implant device. This item/service falls within 
the prosthetic devices 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. The amount you owe for each cochlear implant device is $1,726.20 
($8,630.98 allowed amount x 20% = $1,726.20). The total amount you owe is $3,452.40 ($1,726.20 
coinsurance x 2 items = $3,452.40). Therefore, we decided that the Plan does not have to reduce the 
coinsurance for each cochlear implant device provided on August 11, 2022, to November 10, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the ambulance services provided on 
December 8, 2022. 
 
You asked the Plan to waive the cost share for the ambulance services. You say that you had to be transported 
due to a provider reading an electrocardiogram (EKG) incorrectly. 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. Your 
contract with the Plan says you must pay 10% coinsurance for in-network ambulance services. Your contract with the Plan also says that there is an $800 deductible which applies to in-network ambulance services. 
 
You have been asked to pay $48.24, which is 10% coinsurance of the allowed amount or the ambulance 
services ($482.44 allowed amount x 10% coinsurance = $48.24). This item/service falls within the ambulance 
services benefit category.  
 
You have also been asked to pay $434.20 towards the deductible. This is the remaining amount after applying 
the coinsurance ($482.44 allowed amount - $48.24 coinsurance = $434.20). The Plan has followed Medicare 
rules by clearly disclosing in the contract that there is an $800 deductible which applies to in-network 
ambulance services. This cost sharing is a contractual obligation that had not been met at the time the 
ambulance services was received on December 8, 2022. You have been asked to pay a total of $482.44 ($48.24 
coinsurance + $434.20 deductible = $482.44). 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 cost share for the 
ambulance services provided on December 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 08, 2022. 
 
You asked the Plan to pay for lab services. You say that this is supported in the records. 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 lab services provided on 
December 08, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a foot procedure to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve s foot procedure. You say that this patient needs this procedure for their 
daily life and should have it covered. The Plan denied your request. The Plan says there was no 
preauthorization by a primary care provider (this is different than a referral) for an out-of-network (OON) 
provider or facility. There are other providers who are in-network who can perform this procedure. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal.  
We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided 
that the Plan does not have to pre-approve a foot procedure to be provided by an out-of-network (OON) 
provider.