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

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on July 
01, 2023. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you should not be 
responsible to pay this 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 $250 
copayment for ambulance services.  
You have been asked to pay a $250 copayment for the 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 the ambulance 
services provided on July 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for methadone treatment provided on October 02, 2023. 
 
You asked the Plan to pay for methadone treatment. You say that the provider is enrolled in Medicare. 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 methadone treatment 
provided on October 02, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitoring supplies billed for date of 
service July 4, 2023. 
 
You asked the Plan to pay for the billed services. You say that supporting documentation was provided. The 
Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. The documentation does not show that the 
enrollee has had an in-person visit with their treating physician to evaluate their diabetes control and to 
determine whether the criteria for coverage have been met. Based on this information, we decided that the 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the continuous glucose monitoring supplies billed for date of service July 4, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the duplex scan provided on September 08, 
2023. 
 
You asked the Plan to waive the copayment for the duplex scan. You say that you disagree with the copayment 
for the scan. 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 in-network outpatient diagnostic testing in a specialists office. 
 
You have been asked to pay a $50 copayment for the duplex scan. This item/service falls within the in-network outpatient diagnostic testing in a specialists office 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 duplex scan provided on September 08, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for compression stockings (A6530) provided on July 3, 2023. 
 
You asked the Plan to pay for the compression stockings. You say that the compression stockings are needed 
for your care. The Plan denied your request. The Plan says the requested service is not covered by Medicare or 
the health plan. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the compression stockings have been 
met. Specifically, there were no medical records provided. Without this necessary information, we are unable 
to determine whether the criteria for coverage have been met. The Plan has shown that they made reasonable 
attempts to obtain this necessary information from the provider. Therefore, we decided that the Plan does not 
have to pay for compression stockings (A6530) provided on July 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and related supplies 
provided on June 16, 2023. 
 
You asked the Plan to pay for the billed services. You say that the device reduces incidents of deep vein 
thrombosis. The Plan denied your request. The Plan says equipment used in a facility for a procedure is not 
separately payable. The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The services at issue were provided in an outpatient hospital facility. Although the services may be helpful, 
neither Medicare nor the Plan covers equipment for use outside the home. Additionally, a pneumatic 
compression device compression for the purpose of prevention of venous thromboembolism is excluded from 
coverage under the Medicare durable medical equipment benefit. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device and related supplies provided on June 16, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service September 
10, 2023, to September 23, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that there were no in-network providers 
available in the enrollee's geographic area. The Plan denied your request. The Plan says the billed code is 
invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service September 10, 2023, to September 23, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
October 01, 2023. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you were admitted and 
should not be responsible for the 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 $50 
copayment for emergency care. 
 
You have been asked to pay a $50 copayment for the emergency room visit. 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 visit 
provided on October 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 11721 and 11055-59-Q8 billed for date of 
service May 9, 2023. 
 
You asked the Plan to pay for procedure codes 11721 and 11055-59-Q8. You say that the claim is billed 
correctly and should be paid. The Plan denied your request. The Plan says payment for code 11721 is bundled 
into payment for code 11055. Code 11055 denied as the number of units billed exceeds the maximum allowed.  
 
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 11721 
is a column II code to column I code 11055. This claim has not been billed with an appropriate modifier to 
bypass the edit. Medicare rules say that claims submitted where the unit of service exceeds the MUE value 
cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 11055 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 11721 have not been met. 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 codes 11721 and 11055-59-
Q8 billed for date of service May 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on July 11, 2023, to July 12, 
2023, billed with procedure codes 99308 and 99309. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the documentation does not include a provider's 
signature. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare requires that services 
provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in 
accordance with Medicare's policies. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met. Specifically, the documentation submitted 
does not include a valid signature from the persons responsible for the care of the beneficiary. We find that the 
documentation does include a provider's signature. Therefore, we decided that the Plan does not have to pay for 
practitioner services provided on July 11, 2023, to July 12, 2023, billed with procedure codes 99308 and 
99309.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent cares ervices provided on 
September 22, 2023. 
 
You asked the Plan to waive the copayment for the urgent cares ervices. You say that the cost share is wrong. 
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 urgently needed services. 
 
You have been asked to pay a $40 copayment for the urgent cares ervices. 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 
cares ervices provided on September 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services described by code 
99221-57 performed on date of service September 6, 2023. 
 
You asked the Plan to pay for 99221-57. You say that 99221-57 should be paid as billed because it is supported 
in the documentation and the modifier should allow for separate payment. The Plan denied your request. The 
Plan says 99221-57 is denied because it is included in the global surgery package for code 61645 and was not 
billed with an appropriate modifier to allow separate payment. 
 The Plan must follow Medicare rules. Medicare rules say that modifier -57 is not used with minor surgeries. 
The decision to perform the minor procedure is typically done immediately before the minor procedure and is 
considered a routine preoperative service, and a visit or consultation is not billed in addition to the procedure. 
 
We looked at the file and Medicare rules. In this case, we have confirmed that 99221 with modifier -57 
appended was billed on the same day as the procedure described by code 61645, performed by the same 
provider. Modifier -57 is used to indicate that evaluation and management services on the day before major 
surgery or on the day of major surgery resulted in the decision to perform that major surgery. We have 
confirmed that 61645 has a global surgery indicator of 000, which means it is classified as a minor procedure, 
rather than a major surgery. Per Medicare rules, the decision to perform a minor procedure is included in 
payment for the procedure and modifier -57 is not used with minor surgeries. Based on this information, we 
decided that Medicare rules for coverage of 99221-57 have not been met. Therefore, we decided that the Plan 
does not have to pay for the evaluation and management services described by code 99221-57 performed on 
date of service September 6, 2023.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa for the enrollee.

You asked the Plan to pre-approve Euflexxa. You say that you feel this is the best treatment for the enrollee.
The Plan denied your request. The Plan says that step therapy criteria have not been met.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for Euflexxa. Our
Medical Director states that the plan's preferred hyaluronic acid products are Monovisc, Orthovisc, Synvisc,
and Synvisc One. Euflexxa is a non-preferred product. The case file does not contain documentation of failed
step therapy in this case. Our Medical Director found that the enrollee's condition does not meet step therapy
criteria for Euflexxa.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have
to pre-approve Euflexxa for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic supplies provided on July 4, 2023. 
 
You asked the Plan to pay for the diabetic supplies. You say that you do not agree with the denial of payment, 
we have sent all the appropriate documents. The Plan denied your request. The Plan says you are not enrolled 
in Medicare as a durable medical equipment supplier. Therefore, the claim was denied. 
 
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 diabetic supplies provided on July 4, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hearing exam provided on August 02, 
2023. 
 
You asked the Plan to waive the copayment for the hearing exam. You say that you should not have an 
additional 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 $40 
copayment for hearing services. 
 
You have been asked to pay a $40 copayment for the hearing exam. 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. However, since the allowed amount is less than the standard copayment, you only owe $35.47. Therefore, 
we decided that the Plan does not have to waive the copayment for the hearing exam provided on August 02, 
2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp.  
 
You asked the Plan to pre-approve Aranesp. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
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 Aranesp. Our reviewer says that the 
drug is not medically necessary. Our physician reviewer found based on the medical records provided, requirements of the Local Coverage Determination (LCD) LCD - Erythropoiesis Stimulating Agents (ESAs) 
(L34633) and the Medicare-approved major drug compendia, there is no documentation that Aranesp is 
medically reasonable and necessary for the enrollee. There is no documentation that the Aranesp is safe and 
effective for the enrollee.  Provided medical records do not document laboratory results pertinent to treatment 
such as adequate serum ferritin, serum transferrin saturation and iron levels as required by the LCD and 
standards of care for use of Aranesp.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the ambulance transportations provided 
from December 20, 2022, to February 11, 2023. 
 
You asked the Plan to waive the copayments for the ambulance transportations. You say that the transports are 
the result of negligence from the 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $290 copayment per date of service, for ground ambulance services. The enrollees contract with 
the Plan also clearly says that enrollees must pay a $300 copayment per date of service, for ground ambulance 
services. 
 
The enrollee has been asked to pay a $290 copayment for each ambulance transportation provided on 
December 20, 2022, and December 29, 2022. The enrollee had also been asked to pay a $300 copayment for 
each ambulance transportation provided on February 10, 2023, and February 11, 2023. These items/services 
fall within the ambulance services 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 
copayments for the ambulance transportations provided from December 20, 2022, to February 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on March 30, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the panel should be billed 
with one unit of one code. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab panel provided on March 30, 2023.