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

 
We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on 
June 22, 2023.   
 
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you were told you 
needed to have this test as soon as possible and no one mentioned that you would be responsible for a 
copayment. The Plan denied your request. The Plan says this cost share 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 enrollees must pay a 
$220 copayment for in-network for Medicare-covered outpatient surgical services in an outpatient hospital 
setting. 
 You have been asked to pay a $220 copayment for the diagnostic colonoscopy. This service falls within the 
outpatient surgery benefit category. This means 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 diagnostic colonoscopy 
provided on June 22, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta (J3304). 
 
You asked the Plan to pre-approve the drug. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says the step therapy criteria have not been met.  
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 drug. Our physician reviewer found 
step therapy, as outlined by the Plan, requires a trial of two (2) intra-articular steroids (for example: 
triamcinolone, methylprednisolone, betamethasone, and/or dexamethasone) be trialed first. The documentation 
does not outline contraindications or reasons these medications were not considered or that the Plan's additional 
required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Without the 
support of the documentation, Zilretta is not approved as step criteria have not been met. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Zilretta (J3304).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on August 15, 2023. 
 
You asked the Plan to pay for OIVIT services. The Plan denied your request. The Plan says the services are not 
supported. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for the Outpatient Intravenous Insulin Therapy (OIVIT) services provided on August 15, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued home health skilled services. 
 You asked the Plan to pre-approve home health services. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the records 
show that you have been medically stable without any recent worsening of your chronic medical problems or 
hospitalizations. You do not require additional skilled nursing services to effectively provide treatment, care, 
and/or services in order to improve your condition or perform a maintenance program to maintain your 
condition and/or prevent deterioration.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued home health skilled services.
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 
99222-57 billed for date of service September 10, 2023. 
 
You asked the Plan to pay for 99222-57. You say that 99222-57 should be paid as billed because it represents 
the first time the enrollee was seen by this provider, and it was billed with valid modifier -57. The Plan denied 
your request. The Plan says 99222-57 is denied because it is included in the global surgery package for code 
52356 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 surgery 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 99222 with modifier -57 
appended was billed on the same day as the procedure described by code 52356, 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 52356 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 99222-57 have not been met. Therefore, we decided that the Plan 
does not have to pay for the evaluation and management services described by code 99222-57 billed for date of 
service September 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a CGM. You say that you would like this CGM. The Plan denied your 
request. The Plan says the medical criteria for a CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee has not 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 Medicare rules for coverage of a CGM 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous 
glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a joystick module (K0108), gel footplate cover (K0108), 
footplate width extension (K0108), stealth height adjustable receiver (K0108), foot box (E0954), and arm pad 
assemblies (A9270 x2).  
 
You asked the Plan to pre-approve a joystick module, gel footplate cover, footplate width extension, stealth 
height adjustable receiver, foot box, and arm pad assemblies. You say that you are requesting the items to be 
reconsidered and approved for the patient's power wheelchair so that the equipment being provided to them 
will meet their entire medical needs. The Plan denied your request. The Plan says the requested accessories do 
not primarily serve a medical purpose. The Plan also says that these cannot be covered as they are not 
reasonable and necessary. 
 
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 a joystick module, gel footplate cover, 
footplate width extension, stealth height adjustable receiver, foot box, and arm pad assemblies. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the joystick module is not medically necessary as the patient has adequate strength to 
manage standard power drives. The arm pad assemblies are not medically necessary. Our reviewer found that 
the footplate is not medically necessary as there is no consistent evidence of foot deformity. Our physician 
reviewer also found that the back system is included in the group 3 power wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a joystick module, gel footplate cover, footplate width extension, stealth height 
adjustable receiver, foot box, and arm pad assemblies have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a joystick module (K0108), gel footplate cover (K0108), footplate width 
extension (K0108), stealth height adjustable receiver (K0108), foot box (E0954), and arm pad assemblies 
(A9270 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical connection between the wheelchair 
controller and two or more motors (E2311), a harness (E2313) and an expandable controller (E2377). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the services are not medically necessary. 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the criteria for the requested accessories are not medically necessary per Social 
Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k), as Medicare does not pay for any items or 
services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve 
the functioning of a malformed body member. The enrollee's upper extremity strength and functional ability as 
shown by independent in feeding support that this enrollee can control any power options through their own 
switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electrical connection between the wheelchair controller and two or more 
motors (E2311), a harness (E2313) and an expandable controller (E2377).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for INR home laboratory testing provided on 
September 29, 2023. 
 
You asked the Plan to waive the coinsurance for INR home laboratory testing. You say that you have never had 
to pay a copayment on these items. 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 durable medical equipment (DME) and related supplies. 
 
You have been asked to pay 20% coinsurance for INR home laboratory testing. This item/service falls within 
the durable medical equipment (DME) 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 total you owe is $25.08 ($138.60 x 20% = 
$27.92). You are being asked to pay less than the 20%. Therefore, we decided that the Plan does not have to 
waive the coinsurance for INR home laboratory testing provided on September 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options (K0861) and accessories. 
 
You asked the Plan to pre-approve Group 3 power wheelchair. You say that this is needed to live an 
independent lifestyle. The Plan denied your request. The Plan says the enrollee does not have a medical need 
for the requested power options. 
 
The Plan follows Medicare rules. Medicare rules state that a Group 3 power wheelchair with multiple power 
options (K0861) may be covered if certain criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Group 3 power wheelchair. Our 
reviewer says that the enrollee does not meet criteria for a Group 3 power wheelchair with multiple power 
options. Our physician reviewer found the enrollee has no need for a ventilator or power tilt and recline. The 
documentation does not support that the enrollee is at high risk for development of a pressure ulcer, utilizes 
intermittent catheterization for bladder management, or needs a power seating system to manage increased tone 
or spasticity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Group 3 power wheelchair have not been met. As the power wheelchair base is 
not covered, all related accessories are also denied. Therefore, we decided that the Plan does not have to pre-
approve a Group 3 power wheelchair with multiple power options (K0861) and accessories.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for clinic services related to an inpatient stay from August 4, 
2023, to August 8, 2023. 
 
You asked the Plan to pay for clinic services. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules require payment for certain outpatient services provided 
to a beneficiary on the date of an inpatient admission or during the 3 calendar days (or 1 calendar day for a non-IPPS hospital) prior to the date of an inpatient admission to be bundled (i.e., included) with the Medicare 
Part A payment for the beneficiarys inpatient admission. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of clinic services have not been met. Specifically, the case record shows that the services at issue 
were outpatient services provided on the date of an inpatient admission. As such, payment is bundled into 
payment for the inpatient admission. Therefore, we decided that the Plan does not have to pay for clinic 
services related to an inpatient stay from August 4, 2023, to August 8, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth psychiatry visit provided on September 19, 2023, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for telehealth psychiatry visit. You say that there is no in-office visit option with this 
provider so you can only do telehealth. The Plan denied your request. The Plan says there is no coverage for 
out-of-network telehealth outpatient mental health care services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan includes coverage for out-of-network services; however, there is no coverage for out-of-
network outpatient mental health care telehealth services. 
 Outpatient mental health care telehealth services are not covered when performed by an out-of-network 
provider. Therefore, we decided that the Plan does not have to pay for a telehealth psychiatry visit provided on 
September 19, 2023, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
August 23, 2023. 
 
You asked the Plan to waive the copayment for the emergency room services. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for the emergency room services. 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. However, since the allowed amount is less than the copay, you only owe $80.79. Therefore, we 
decided that the Plan does not have to waive the copayment for the emergency room services provided on 
August 23, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound of the bladder provided on 
July 25, 2023. 
 
You asked the Plan to waive the copayment for the ultrasound of the bladder. You say that you would like to 
know why the ultrasound was not 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 $250 
copayment for advanced imaging services. 
 
You have been asked to pay a $250 copayment for the ultrasound of the bladder. This item/service falls within 
the advanced imaging 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 $58.79. Therefore, we decided that the Plan does not have to waive the copayment for the ultrasound 
of the bladder provided on July 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 96365, defined as intravenous infusion, for therapy, 
prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour, and J3032, defined as injection, 
eptinezumab-jjmr, 1 milligram, performed on date of service September 15, 2022. 
 
You asked the Plan to pay for 96365 and J3032. You say that 96365 and J3032 should be paid as billed because 
these services were actually rendered, and the claim with frequency code 8 was submitted in error. The Plan 
denied your request. The Plan says 96365 and J3032 are denied because they were billed on a claim with 
frequency code 8. 
 
The Plan must follow Medicare rules. Medicare rules say that frequency code 8 on the claim form indicates the 
voiding or cancellation of a prior claim. 
 We looked at the file and Medicare rules. In this case, we confirmed that the claim in question included a field 
for a frequency code, which was reported as 8. Frequency code 8 indicates the intention to void or cancel a 
prior claim. This means that the claim is a void of a previously submitted claim. Payment cannot be made for a 
claim with a frequency code of 8. Based on this information, we decided that Medicare rules for coverage of 
96365 and J3032 have not been met. Therefore, we decided that the Plan does not have to pay for codes 96365, 
defined as intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 
1 hour, and J3032, defined as injection, eptinezumab-jjmr, 1 milligram, performed on date of service 
September 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided April 21, 2023, to 
April 25, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says there were no complications, and the enrollee 
was discharged.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the inpatient admission was not medically necessary, as lower level of service (e.g. 
observation) would have been able to address the medical issues. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided April 21, 2023, to April 25, 2023.