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

 
We decided that the Plan does not have to waive the coinsurance for the chiropractic services provided on 
January 10, 2023. 
 
You asked the Plan to waive the coinsurance for the chiropractic services. You say that you were told you 
would be reimbursed a larger amount. 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 50% 
coinsurance for out-of-network chiropractic services.  
You have been asked to pay 50% coinsurance for the chiropractic services. This item/service falls within the 
out-of-network chiropractic 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 $19.08 ($38.17 allowed amount x 50% coinsurance = 
$19.08). Therefore, we decided that the Plan does not have to waive the coinsurance for the chiropractic 
services provided on January 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the chiropractic services provided on 
December 28, 2022. 
 
You asked the Plan to waive the coinsurance for the chiropractic services. You say that you were told you 
would be reimbursed a larger amount. 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 50% 
coinsurance for out-of-network chiropractic services.  
You have been asked to pay 50% coinsurance for the chiropractic services. This item/service falls within the 
out-of-network chiropractic 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 $19.16 ($38.32 allowed amount x 50% coinsurance = 
$19.16). Therefore, we decided that the Plan does not have to waive the coinsurance for the chiropractic 
services provided on December 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the chiropractic services provided on 
January 24, 2023. 
 
You asked the Plan to waive the coinsurance for the chiropractic services. You say that you were told you 
would be reimbursed a larger amount. 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 50% 
coinsurance for out-of-network chiropractic services.  
You have been asked to pay 50% coinsurance for the chiropractic services. This item/service falls within the 
out-of-network chiropractic 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 $19.08 ($38.17 allowed amount x 50% coinsurance = 
$19.08). Therefore, we decided that the Plan does not have to waive the coinsurance for the chiropractic 
services provided on January 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telephone evaluation and management service and remote 
physiologic monitoring treatment management services provided on July 08, 2022, to August 31, 2022. 
 
You asked the Plan to pay for telephone evaluation and management service and remote physiologic 
monitoring treatment management services. You say that the services should be covered. 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 telephone evaluation and 
management service and remote physiologic monitoring treatment management services provided on July 08, 
2022, to August 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on January 23, 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 January 23, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the abdominal ultrasound provided on May 
10, 2023. 
 
You asked the Plan to waive the copayment for the abdominal ultrasound. You say that you were told this 
copayment would be $15. 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 $75 
copayment for in-network outpatient diagnostic tests, including ultrasounds. 
 
You have been asked to pay a $75 copayment for the abdominal ultrasound. This item/service falls within the 
in-network outpatient diagnostic tests, including ultrasounds 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 abdominal ultrasound provided on May 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services provided on July 13, 2022. 
 
You asked the Plan to pay for the podiatry services. You say that you were given incorrect insurance 
information from the enrollee. 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 podiatry services 
provided on July 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual routine exam provided on May 9, 2023. 
 
You asked the Plan to pay for annual routine exam. You say that you feel it should be paid. The Plan denied 
your request. The Plan says an annual routine exam is covered once per year. You previously received this 
service on April 3, 2023. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for an annual routine exam provided on May 9, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Abilify. 
 
You asked the Plan to pre-approve the medication. You say that you disagree with the denial. 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 Abilify.   
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an open implantation of neurostimulator electrode array. 
 
You asked the Plan to pre-approve sacral nerve transforaminal placement. You say that this procedure is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the requested surgery has 
been correctly denied. 
 
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 sacral nerve transforaminal placement. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the case file does not contain documentation of a successful 
percutaneous test stimulation, defined as at least 50% sustained (more than one week) improvement in 
symptoms.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacral nerve transforaminal placement have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an open implantation of neurostimulator electrode array.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97598 billed for date of service May 30, 
2023. 
 You asked the Plan to pay for procedure code 97598. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 97598 is bundled into 
payment for code 11043. 
 
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 97598 
is a column II code to column I code 11043. 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 97598 billed for date of service May 30, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95870 provided on December 20, 2022. 
 
You asked the Plan to pay for procedure code 95870. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the provider is not eligible to bill Medicare. 
 
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. 
 
We looked at the file and Medicare rules. The file shows that this provider is a Specialist/Technologist, Other -
Electroneurodiagnostic and is not defined by Medicare as a physician/practitioner. Therefore, we decided that 
the Plan does not have to pay for procedure code 95870 provided on December 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cologuard test provided on January 08, 2023. 
 
You asked the Plan to pay for a cologuard test. You say that you believe this is a covered service. 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 a cologuard test 
provided on January 08, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for an x-ray, a betamethasone injection, and a 
hand finger orthosis provided on March 16, 2023. 
 
You asked the Plan to reduce the cost share for an x-ray, an injection, and a hand finger orthosis. You say that 
you disagree with the 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 $20 
copayment for most x-rays. Your contract with the Plan also clearly says that you must pay 20% coinsurance 
for Medicare Part B prescription drugs. Your contract with the Plan also clearly says that you must pay 20% 
coinsurance for durable medical equipment and related supplies. 
 
You have been asked to pay a $20 copayment for an x-ray. This item/service falls within the outpatient 
diagnostic tests and therapeutic 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.  
 
You have been asked to pay $2.78, which is 20% coinsurance of the allowed amount for the injection ($13.88 
allowed amount x 20% = $2.78). This item/service falls within the Medicare Part B prescription drugs benefit 
category. You have also been asked to pay $18.25, which is 20% coinsurance of the allowed amount for the 
hand finger orthosis ($91.27 allowed amount x 20% = $18.25). This item/service falls within the durable 
medical equipment and related supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the cost share 
for an x-ray, a betamethasone injection, and a hand finger orthosis provided on March 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home sleep test provided on August 9, 2022, by an OON 
provider.  
 
You asked the Plan to pay for the home sleep test. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the home sleep test provided on August 9, 2022, 
by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 25, 2023, billed with 
code 87500. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 25, 2023, billed with code 87500.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a comprehensive hearing test provided on 
May 18, 2023. 
 
You asked the Plan to waive the copayment for a comprehensive hearing test. You say that you were already 
charged an additional copayment for services received on the same date. 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 Medicare-covered diagnostic hearing exams. 
 
You have been asked to pay a $45 copayment for a comprehensive hearing test. This item/service falls within 
the Medicare-covered diagnostic hearing exams 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 comprehensive hearing test provided on May 18, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on March 11, 
2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with 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 $330 
copayment for ambulance services. 
 
You have been asked to pay a $330 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 March 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the needle electromyography services provided on November 
10, 2022.  
You asked the Plan to pay for the needle electromyography services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable for this provider. 
 
The Plan must follow Medicare rules. Medicare rules say that services are only covered when provided by a 
valid physician/practitioner.  
 
We looked at the file and Medicare rules. Review of the file shows that the provider has a taxonomy number as 
a specialist/technologist- electro neurodiagnostic technician. This means the provider was not certified/eligible 
to be paid for this procedure. Based on this information, we decided that Medicare rules for coverage of the 
needle electromyography services have not been met. Therefore, we decided that the Plan does not have to pay 
for the needle electromyography services provided on November 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652), a segmental 
pneumatic appliance for use with pneumatic compressor, trunk (E0656x13) and a segmental pneumatic 
appliance for use with pneumatic compressor, full arm (E0668). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that you are 
requesting reconsideration and have provided medical records for review.  The Plan denied your request. The 
Plan says the records do not show at least four-week trial of daily, multiple-hour home usage of the basic pump 
(E0650 or E0651). You do not meet criteria for approval. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652), a segmental pneumatic appliance for use with pneumatic compressor, trunk (E0656x13) and a 
segmental pneumatic appliance for use with pneumatic compressor, full arm (E0668).