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

 
We decided that the Plan does not have to pre-approve Botox (onabotulinumtoxina). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 medication. Our reviewer says that 
the medication is not medically necessary. Our physician reviewer found based on the medical records 
provided and the Medicare-approved major drug compendia there is no documentation that the Botox at issue 
in this case meets all Medicare criteria for medically reasonable and necessary for the patient. Review of the 
Medicare-approved major drug compendia does not indicate that Raynaud's syndrome is a medically accepted 
indication for Botox injections. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Botox (onabotulinumtoxina).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility provided on 
February 09, 2023, to February 22, 2023. 
 
You asked the Plan to waive the copayment for skilled nursing facility. You say that you were told this was a 
new stay and it should be at no cost. 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 $1113 
copayment for Skilled Nursing Facility (SNF) Care. 
 
You have been asked to pay a $1113 copayment for skilled nursing facility. This item/service falls within the 
Skilled Nursing Facility (SNF) 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. a copayment amount of $196 for days 53 to 59 for Skilled Nursing Facility 
Care. The copayment amount of $1,176.00 ($196 x 6 days) is correct. You met your out-of-pocket maximum 
on this claim therefore, the your responsible for $1,113.00. Therefore, we decided that the Plan does not have 
to waive the copayment for skilled nursing facility provided on February 09, 2023, to February 22, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on March 17, 2022, to April 
15, 2022. 
 
You asked the Plan to pay for home health services. You say that you are appealing the claim payment denial. 
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 home health services 
provided on March 17, 2022, to April 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a positron emission tomography/computed tomography 
(PET/CT) scan rendered on January 27, 2023. 
 
You asked the Plan to pay for the scan. You say that this should be paid for. The Plan denied your request. The 
Plan says this was not billed with an appropriate diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
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 scan. Our reviewer says that the services 
at issue in this case were not medically reasonable or necessary. Our physician reviewer found that the PET/CT 
done on 1/27/23 listed as the indication for the scan "malignant melanoma.'  While this tumor is an indication for the scan, the Medicare rules state more information including the site of the tumor be included in the 
indication in order for a proper ICD-10 code to be applied. This was not included in the dictated indication for 
the scan. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pay for a positron emission tomography/computed tomography (PET/CT) scan rendered on January 27, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for diabetic supplies provided on April 25, 
2023. 
 
You asked the Plan to reduce the coinsurance for diabetic supplies. You say that you were told your 
responsibility would be less than what the bill says. 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 diabetes self-management training, diabetic services and supplies. 
 
You have been asked to pay 20% coinsurance for diabetic supplies. This item/service falls within the diabetes 
self-management training, diabetic 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. The total you owe is $101.62 ($508.11 allowed amount x 
20% = $101.62) Therefore, we decided that the Plan does not have to reduce the coinsurance for diabetic 
supplies provided on April 25, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 33508, 33522, and 33533 rendered on March 
17, 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 denied Current Procedural Terminology (CPT) codes remain not supported. 
 
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 the denied codes is: 
 
CPT 33508: 
 
Endoscopy, surgical, including video-assisted harvest of vein(s) for coronary artery bypass procedure (List separately in addition to code for primary procedure) 
 
CPT 33522: 
 
Coronary artery bypass, using venous graft(s) and arterial graft(s); 5 venous grafts (List separately in addition 
to code for primary procedure) 
 
CPT 33533: 
 
Coronary artery bypass, using arterial graft(s); single arterial graft 
 
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 
contain a procedure report that verifies the denied codes. 
 
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 33508, 33522, and 33533 rendered on March 17, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation. 
 
You asked the Plan to pre-approve additional transportation. The Plan denied your request. The Plan says your 
benefit for transportation is 12 one-way trips per year, and the documentation from the Plans transportation 
vendor shows that you have used all 12 one-way trips. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of a total of 12 one-way non-emergency ground transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional transportation.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each occupational therapy (OT) visit 
provided on April 06, 2023. 
 
You asked the Plan to waive the copayment for each occupational therapy (OT) visit. You say that you 
expected the visit to be fully covered. 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 $40 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $40 copayment for each occupational therapy (OT) visit. This item/service falls 
within the outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for each occupational therapy (OT) visit provided on April 06, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit provided 
on March 06, 2023, to March 29, 2023. 
 
You asked the Plan to waive the copayment for each physical therapy (PT) visit. You say that the PT visits 
should be covered completely with no copayment. 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 outpatient rehabilitation services. 
 
You have been asked to pay a $30 copayment for each physical therapy (PT) visit. This item/service falls 
within the outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. The total you owe is $240 for PT visits ($30 each visit x 8 visits = $240). 
Therefore, we decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit 
provided on March 06, 2023, to March 29, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service January 20, 
2023.  
 
  You asked the Plan to pay for procedure code 99285. You say that this claim was billed with a different 
rendering provider name, and a different place of service. You also say that you would like this claim to be 
reprocessed for payment. The Plan denied your request. The Plan says payment for code 99285 is bundled into 
payment for code 99221. 
 
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 99285 
is a column II code to column I code 99221 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 99285 billed for date of service January 20, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit provided 
on May 09, 2023. 
 
You asked the Plan to waive the copayment for each physical therapy (PT) visit. You say that you did not 
chose to do PT and should not have to pay a $30 copayment for each visit. 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 outpatient rehabilitation services. 
 
You have been asked to pay a $30 copayment for each physical therapy (PT) visit. This item/service falls 
within the outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for each physical therapy (PT) visit provided on May 09, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on March 1, 2023. 
 
The enrollee asked the Plan to pay for the ambulance response and treatment with no transport. The enrollee 
says that they had been fighting diabetic drops at night, and the decision was made to call the ambulance. The 
enrollee also says that once the help arrived and they were treated, it was agreed that they were in a good stable 
place not to go to the hospital. The Plan denied the enrollees request. The Plan says the available information 
shows that the enrollee was evaluated and declined transport to the emergency room. 
 
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 March 1, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on March 1, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a visual field assessment (0379T) provided 
on January 21, 2023, to April 21, 2023. 
 
You asked the Plan to waive the copayment for a visual field assessment (0379T). You say that you were not 
charged this in 2022. You also say you were told your benefits did not change in 2023. 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 $50 
copayment for diagnostic procedures/tests. 
 
You have been asked to pay a $50 copayment for a visual field assessment (0379T). This item/service falls 
within the diagnostic procedures/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 
visual field assessment (0379T) provided on January 21, 2023, to April 21, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Wegovy auto-injector. 
 
You asked the Plan to pre-approve the medication. You say that this medication would immensely help you. 
The Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
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 Wegovy auto-injector.   
Benefits for the medication 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on January 05, 2022, 
to January 22, 2022.  
 
You asked the Plan to waive the copayment for inpatient hospital stay. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $320 copayment per day for days 1-5, $0 copayment per day for days 6 and beyond for inpatient 
hospital care. Includes inpatient acute, inpatient rehabilitation, long-term care hospitals, and other types of 
inpatient hospital services. Inpatient hospital care starts the day you are formally admitted to the hospital with a 
doctors order. The day before you are discharged is your last inpatient day. 5 x $320 = $1,600. Therefore, 
results in the total cost sharing amount of $1,600. 
 
The enrollee has been asked to pay a $320 copayment for inpatient hospital stay. This item/service falls within 
the inpatient hospital care benefit category. This means that the enrollee has been asked to pay the correct 
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to 
pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
inpatient hospital stay on January 05, 2022, to January 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), 
periapical first x-ray (D0220 x 3), periapical each additional x-ray (D0230), problem focused limited oral 
evaluation (D0140), prophylaxis (D1110), bitewing x-rays (D0274), topical application of fluoride varnish 
(D1206) and core buildup (D2950) provided from January 9, 2023, to March 20, 2023. 
 You asked the Plan to pay for the dental services. You say that you purchased additional dental coverage 
through the Plan, and they are now your primary dental plan.  The Plan denied your request. The Plan says they 
are not your primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the dental services until the primary insurer has denied the claim for these services. Therefore, we decided 
that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), periapical first x-
ray (D0220 x 3), periapical each additional x-ray (D0230), problem focused limited oral evaluation (D0140), 
prophylaxis (D1110), bitewing x-rays (D0274), topical application of fluoride varnish (D1206) and core 
buildup (D2950) provided from January 9, 2023, to March 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 15, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
March 15, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on April 5, 2023. 
 
You asked the Plan to pay for the emergency room services. You say that you would like this claim to be 
reprocessed and paid. The Plan denied your request. The Plan says per internal review no provider or supplier 
shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is 
enrolled in the Medicare program. The Plan says further, it is essential that each provider and supplier enroll 
with the appropriate Medicare Administrative Contractor. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the emergency room services provided 
on April 5, 2023.