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

 
We decided that the Plan does not have to reduce the copayment for an in-network international normalised 
ratio (INR) blood test provided on January 04, 2023. 
 
You asked the Plan to reduce the copayment for an in-network international normalised ratio (INR) blood test. 
You say that this should be covered because last year you only had to pay $10 every 3 months for this service. 
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 other outpatient diagnostic tests. 
 
You have been asked to pay a $20 copayment for an in-network international normalised ratio (INR) blood test. 
This item/service falls within the other outpatient diagnostic 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 reduce the copayment for an in-network international normalised ratio (INR) blood test provided on January 
04, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 06, 2022. 
 
You asked the Plan to pay for lab services. You say that this is supported in the records. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab services provided on 
December 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hearing exams provided on February 
08, 2023. 
 
You asked the Plan to waive the copayment for the hearing exams. You say that you thought the exam was 
routine and would be 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 $50 
copayment for hearing services. 
 
You have been asked to pay a $50 copayment for the hearing exams. 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. Therefore, we decided that the Plan does not have to waive the copayment for the hearing exams 
provided on February 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on October 12, 2022. 
 
You asked the Plan to pay for the office visit. You say that this provider was the only one available to render 
these services. 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 office visit provided 
on October 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor (E0652) and segmental 
pneumatic appliance for use with pneumatic compressor, full leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compressor and full leg segmental pneumatic appliance. You 
say that the services are necessary. The Plan denied your request. The Plan says based on the documentation 
provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PCD coded as E0652, is covered for the treatment 
of lymphedema extending onto the chest, trunk and/or abdomen when specific 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 a pneumatic compressor and full leg 
segmental pneumatic appliance. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found based on the medical records provided there is no documentation that the pneumatic 
compressor, segmental home model with calibrated gradient pressure (E0652) and a segmental pneumatic appliance (E0667) at issue in this case meet all Medicare criteria for medically reasonable and necessary for 
you. Provided records in this case do not document at least four weeks of regular, daily, multiple-hour home 
usage of a basic pump after careful, in-person fitting, training and supervision by a technician who is skilled in 
and who regularly and successfully uses the appliance provided. 
 
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 pneumatic compressor and full leg segmental pneumatic appliance have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compressor (E0652) 
and segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for group psychotherapy provided on November 08, 2022. 
 
You asked the Plan to pay for group psychotherapy. 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 group psychotherapy 
provided on November 08, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for in-network urological supplies provided 
on January 18, 2023. 
 
You asked the Plan to waive the coinsurance for in-network urological supplies. You say that you have been 
having urology issues for years, and need more of these items for your everyday life. You are asking for any 
help that can be given. 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 in-network urological supplies. 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 allowed amount of this item is $897.60, 
resulting in a coinsurance amount of $179.52 ($897.60 x 20% = $179.52). Therefore, we decided that the Plan 
does not have to waive the coinsurance for in-network urological supplies provided on January 18, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the chemotherapy injections provided on 
June 9, 2022. 
 
You asked the Plan to waive the coinsurance for the chemotherapy. You say that the enrollee should have met 
their maximum out-of-pocket 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). The enrollees contract with the Plan clearly says that enrollees 
must pay 20% coinsurance for Part B chemotherapy drugs.  
 
The record shows the enrollee had not met their maximum out-of-pocket amount at the time of service. The 
enrollee has been asked to pay 20% coinsurance for the chemotherapy. These items/services fall within the 
Medicare Part B prescription drugs benefit category.  
 
Date of Service Item Allowed Amount 20% Coinsurance 
June 9, 2022 Chemotherapy injection $3.12 $0.62 
June 9, 2022 Chemotherapy injection $1.38 $0.28 
June 9, 2022 Chemotherapy injection $37.80 $7.56 
June 9, 2022 Chemotherapy injection $11.16 $2.23 
June 9, 2022 Chemotherapy injection $5.04 $1.01 
June 9, 2022 Chemotherapy injection $45.36 $9.07 
June 9, 2022 Chemotherapy injection $357.72 $71.54 
June 9, 2022 Chemotherapy injection $143.08 $28.62 
June 9, 2022 Chemotherapy injection $3,623.40 $724.68 
June 9, 2022 Chemotherapy injection $13,776.89 $275.38 
June 9, 2022 Chemotherapy injection $72.46 $14.49 
June 9, 2022 Chemotherapy injection $1.09 $0.22 
 
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 coinsurance for the chemotherapy injections provided on June 
9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist services provided on January 
01, 2023. 
 
You asked the Plan to waive the copayment for the specialist services. You say that you were not aware you 
would be charged for electronic messaging with your provider. 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 $35 
copayment for in-network specialist physician/practitioner services. 
 
You have been asked to pay a $35 copayment for the specialist services. This item/service falls within the in-
network specialist physician/practitioner services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. This is considered a telehealth service and the specialist 
copayment applies. However, since the allowed amount is less than the standard copayment, you only owe 
$15.28. Therefore, we decided that the Plan does not have to waive the copayment for the specialist services 
provided on January 01, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 20, 2022, to 
July 28, 2022. 
 You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and the rules. The claim was billed with a type of bill 322. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the home health services provided from July 20, 2022, to July 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardigram (TTE). 
 
You asked the Plan to pre-approve a TTE. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that echocardiography is indicated in the evaluation of 
derangements of valvular, myocardial and pericardial structure and function. 
 
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 TTE. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found clinical guidelines do not support carrying 
out a TTE in this setting. In summary, there is no supportive evidence for the medical necessity of a TTE in this 
this patients clinical management. 
 
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 TTE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a transthoracic echocardigram (TTE).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service December 2, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service December 2, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on December 
29, 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 $350 
copayment for ambulance services. 
 
You have been asked to pay a $350 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 December 29, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint (SIJ) injection. 
 
You asked the Plan to pre-approve an SIJ injection. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that sacroiliac joint injections (SIJI) will be considered 
medically reasonable and necessary when specific requirements 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 an SIJ injection. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee does not meet evidence-
based criteria as there is noted L5-S1 central disc bulge with disc contacting the exiting L5 nerve root, and 
moderate to severe bilateral foraminal narrowing per the lumbar magnetic resonance imaging (MRI). 
Additionally, there are not at least three positive provocation tests documented, with mention of only a positive 
Patricks (FABER) test. The review has determined that the enrollee does not meet the coverage criteria 
detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an SIJ injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac joint (SIJ) injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on January 19, 
2023. 
 
You asked the Plan to pay for an office visit and related 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 an office visit and 
related services provided on January 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a radiofrequency ablation (RFA) procedure (99152, 
64633, 64634). 
 
You asked the Plan to pre-approve a RFA procedure. You say that you are appealing for a repeat 
radiofrequency ablation procedure, and you would like this reviewed for medical necessity. The Plan denied 
your request. The Plan says the benefit limit is exhausted 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare will only cover two RFA procedures per 12 month rolling 
calendar. The medical records show that the enrollee received an RFA procedure on May 17, 2022, and July 
14, 2022. The benefit limit will be exhausted until May 17, 2023. Based on this information, we decided that 
Medicare rules for coverage of a RFA procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a radiofrequency ablation (RFA) procedure (99152, 64633, 64634).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room service provided on 
January 13, 2023. 
 
You asked the Plan to waive the copayment for the emergency room service. You say that you did not receive 
any treatment from the provider. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for the emergency room service. This item/service falls within 
the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. The record shows you received an evaluation during the emergency room service. Therefore, we 
decided that the Plan does not have to waive the copayment for the emergency room service provided on 
January 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital observation provided on 
October 27, 2022, to November 03, 2022. 
 
You asked the Plan to waive the copayment for outpatient hospital observation. 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 $195 
copayment for outpatient hospital observation. 
 
You have been asked to pay a $195 copayment for outpatient hospital observation. This item/service falls 
within the outpatient hospital observation 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 outpatient hospital observation provided on October 27, 2022, to November 03, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74019 billed for date of service November 6, 
2022. 
 You asked the Plan to pay for procedure code 74019. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 74019 is bundled into payment for code 
74022. 
 
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 74019 
is a column II code to column I code 74022. 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 74019 billed for date of service November 6, 
2022.