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

 
We decided that the Plan does not have to waive the copayment for the specialist services rendered. 
 
You asked the Plan to waive the copayment for these services. You say that you already paid $50 on the day of 
the visit. The Plan denied your request. The Plan says the copayment was applied 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 each specialist visit for Medicare-covered services.  
 
Review of the file shows that you received specialist services. You have been asked to pay a 
$50 copayment for these services. These services fall within the specialist visit for Medicare-covered 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 specialist services rendered.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services (99213, 72100, 98941) provided April 
4, 2020, to June 30, 2020. 
 
You asked the Plan to pay for the chiropractic services. You say that the services should be covered. The Plan 
denied your request. The Plan says the services at issue are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic services (99213, 72100, 98941) provided April 4, 2020, to June 
30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a 
participating provider on April 13, 2020 to July 13, 2020. 
 
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you believe this is 
fraud. The Plan denied your request. The Plan says the correct coinsurance has been applied. 
 
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% 
coinsurance for durable medical equipment/in-network.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The 
total allowed amount is $1,000. The total amount you are being asked to pay is $200 ($1,000 x 20% = $200). 
Durable medical equipment falls within the durable medical equipment/in-network 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 coinsurance for durable medical equipment provided by a participating 
provider on April 13, 2020, to July 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a litholapaxy provided on June 1, 2020. 
 
You asked the Plan to waive the deductible for a litholapaxy. You say that you already paid the $350 
deductible prior to receiving the services and disagree with the charges. The Plan denied your request. The Plan 
says the claims were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1,000 deductible for outpatient surgery, including services provided 
at hospital outpatient facilities and ambulatory surgical centers.  
 
You received a litholapaxy on June 1, 2020. The record shows that you had paid $0 toward the $1,000 
deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $432.80.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The Plan 
has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible for outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. This cost 
sharing is a contractual obligation that had not been met at the time a litholapaxy was received on June 1, 2020. 
Therefore, we decided that the Plan does not have to waive the deductible for a litholapaxy provided on June 1, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a 
participating provider on July 1, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you only had a 10-minute 
meeting. You say that nothing was done during this time. The Plan denied your request. The Plan says the 
correct copayment has been applied. 
 
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 physician/practitioner services/specialist.  
 
You have been asked to pay a $45 copayment for a specialist office visit. Since a specialist office visit did 
occur, the correct copayment has been applied. A specialist office visit falls within the physician/practitioner 
services/specialist 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 specialist office 
visit provided by a participating provider on July 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cystourethroscopy provided. 
 
You asked the Plan to waive the copayment for a cystourethroscopy. You say that you cannot afford the 
charges and request the claims to be reviewed. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct amount. 
 
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 $295 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You received a cystourethroscopy on June 23, 2020. A cystourethroscopy is considered an outpatient surgical 
procedure. Therefore, you are responsible to pay the $295 copayment.   
 
You have been asked to pay a $295 copayment for a cystourethroscopy. A cystourethroscopy falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 cystourethroscopy provided.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the 
head or brain without contrast (70450) provided on February 16, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $225 
copayment for each Medicare-covered advanced imaging service (not including x-rays). If advanced imaging 
services are received as part of an emergency department evaluation then you will only pay the advanced 
imaging copayment, not the emergency room copayment.  
 
You have been asked to pay a $225 copayment for the advanced imaging service provided at the emergency 
department visit. 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 computed tomography (CT) 
scan of the head or brain without contrast (70450) provided on February 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lower partial denture (D5226). 
 
You asked the Plan to pre-approve the lower partial denture (D5226). You say that you accidentally lost your 
lower partial and need it replaced. The Plan denied your request. The Plan says the service requested is only 
covered once every five plan years. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of 
one lower partial denture every five plan years. The Plan paid for a lower partial denture provided on October 
4, 2018, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the 
lower partial denture (D5226).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network home health provider. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no extenuating circumstances related to geographic access,compelling 
continuity of care making it medically necessary that future care come only from this provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to an out-of-network home health provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 86077) provided on May 20, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 86077 is not supported in the medical record. Specifically, the records do not show that 
an additional unit of CPT 86077 was provided on May 20, 2020. The Plan has approved payment for one unit 
of CPT 86077. The documentation submitted does not show that Medicare coverage criteria have been met for 
these services. Based on this information, we decided that Medicare rules for coverage of the services have not 
been met. Therefore, we decided that the Plan does not have to pay for the services (CPT 86077) provided on 
May 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit and coinsurance for 
an injection provided by a participating provider on March 13, 2020, to June 15, 2020. 
 
You asked the Plan to waive the copayment and coinsurance for a specialist office visit and an injection. You 
say that you do not feel like you should owe this much. The Plan denied your request. The Plan says the correct 
copayment and coinsurance have been applied. 
 
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 $10 
copayment for physician/practitioner services/specialist/in-network and a 20% coinsurance Medicare Part B 
prescription drugs/in-network.  
 
You have been asked to pay a $10 copayment for a specialist office visit and a 20% coinsurance of the allowed 
amount for an injection. The total allowed amount is $2,445.90. The amount you are being asked to pay for 
injections is $489.18 ($2,445.90 x 20% = $489.18). The total amount you are being asked to pay is $509.18 
($10 + $10 + $489.18 = $509.18). A specialist office visit falls within the physician/practitioner 
services/specialist/in-network benefit category and an injection falls within the Medicare Part B prescription 
drugs/in-network 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 specialist office visit and coinsurance for an 
injection provided by a participating provider on March 13, 2020, to June 15, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an Immunoglobulin E measurement 
(82785) performed. 
 
You asked the Plan to waive the copayment for an Immunoglobulin E measurement. You say that this 
copayment should be waived because the service was related to COVID-19. The Plan denied your request. The 
Plan says the correct copayment was applied. 
 
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 $10 
copayment for Medicare-covered laboratory tests.  
 
In this case, medical records supplied by the provider do not support that the service in dispute was related to 
COVID-19. Therefore, you have been asked to pay a $10 copayment for an Immunoglobulin E measurement. 
An Immunoglobulin E measurement 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. Therefore, we decided that the Plan does not have to waive the copayment for an Immunoglobulin E 
measurement (82785) performed.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prednisone. 
 
You asked the Plan to pre-approve Prednisone. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
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 Prednisone.  
 
Benefits for Prednisone 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5225). 
 
You asked the Plan to pre-approve the maxillary partial denture. You say that you are unable to eat solid foods, 
and have only been eating liquids. The Plan denied your request. The Plan says this service is not covered 
under your plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
maxillary partial denture (D5225).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a surgical pathology procedure provided 
on June 22, 2020. 
 
You asked the Plan to waive the coinsurance for a surgical pathology procedure. You say that you already paid 
the $295 copayment and disagree with the additional charges. The Plan denied your request. The Plan says the 
claims were processed correctly, and you are being charged the correct amount. 
 
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 diagnostic procedures and tests. 
 
You received a surgical pathology procedure on June 22, 2020. The allowed amount is $76.12 and 20% of that 
is $15.22.  
 
You have been asked to pay the total coinsurance amount of $15.22 for a surgical pathology procedure. A 
surgical pathology procedure 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. 
Therefore, we decided that the Plan does not have to waive the coinsurance for a surgical pathology procedure 
provided on June 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the radiation services received from 
January 3, 2019 to February 19, 2019. 
 
You asked the Plan to waive the coinsurance for the radiation services. You say that you disagree with the 
amount owed. The Plan denied your request. The Plan says the claims have been processed correctly per your 
plan benefits. 
 
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 therapeutic radiology services.  
 
You have been asked to pay 20% coinsurance for the radiation services. The radiation services fall within the 
therapeutic radiology 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 coinsurance for the 
radiation services received from January 3, 2019 to February 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services for the 
enrollee 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 
setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Long term 
acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide 
clinical services that are materially different than those of short term acute care hospitals. The enrollee is 
receiving acute hospital care, and acute care services have not been denied. The documentation does not 
support that the enrollee in this case requires services at the LTACH that are not available at the acute care 
hospital where he is currently receiving care. Our physician reviewer found that the enrollee's condition does 
not meet Medicare criteria for LTACH services. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long-term acute care hospital (LTACH) services for the enrollee
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for a blood transfusion (36430) and an 
intravenous infusion (96365) performed on June 2, 2020. 
 
The enrollee asked the Plan to waive the cost-sharing for a blood transfusion and an intravenous infusion. The 
enrollee says that the copayments were covered on transfusions until this one since the out-of-pocket cost limit 
was reached in April. The Plan denied the enrollee's request. The Plan says the correct cost-sharing was 
applied. 
 
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 enrollee's contract with the Plan clearly says that enrollees 
must pay a $225 copayment for each Medicare-covered outpatient hospital facility visit. The Plan contract also 
says that enrollees must pay 20% coinsurance for each Medicare-covered Part B drug. 
 
In this case, Plan records document that the enrollee did not reach the out-of-pocket limit until the services in 
dispute were rendered on June 2, 2020. Therefore, the enrollee has been asked to pay a $225 copayment for a 
blood transfusion. The enrollee has also been asked to pay $36.14, or 20% of the Plan-allowed amount of 
$180.70, for an intravenous infusion. A blood transfusion falls within the "Outpatient hospital services" benefit 
category. An intravenous infusion falls within the "Medicare Part B prescription drugs" 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 when enrolling in the Plan. Therefore, we decided 
that the Plan does not have to waive the cost-sharing for a blood transfusion (36430) and an intravenous 
infusion (96365) performed on June 2, 2020.