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

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on March 9, 
2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you were told there would 
only be a $35 copayment. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $225 
copayment for Medicare-covered ambulance transport (one-way).  
 
You have been asked to pay $225 copayment for ambulance transport. Ambulance transport 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 transport 
provided on March 9, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) of head or brain (70435), 
and hip x-ray with pelvis (73502) provided on December 25, 2021. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the computed tomography (CT) of head or brain (70435), and 
hip x-ray with pelvis (73502) provided on December 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the refraction service (92015) provided on April 20, 
2022. 
 
You asked the Plan to pre-approve the vision service. You say that you went to check if you had cataracts. You 
say that you had a referral. You say that the provider accepted your insurance. You also say that you did not know about the vision refraction. The Plan denied your request. The Plan says eye refractions are only covered 
when performed by a participating Vision Plan provider and performed as a routine screening. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers eye refractions are only covered when performed by a participating Vision Plan 
provider and performed as a routine screening. 
 
We looked at the file and the Plan's rules. Eye refractions are only covered when performed by a participating 
Vision Plan provider and performed as a routine screening. Based on this information, we decided that the 
Plan's rules for coverage of the vision service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the refraction service (92015) provided on April 20, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on April 
17, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you are on a fixed income 
and cannot afford this copayment. The Plan denied your request. The Plan says you were charged this cost 
sharing 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 $325 
copayment for each ambulance trip. You had one ambulance trip(s). The Plan charged you $325 for these 
services. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the ambulance services provided on April 17, 
2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visit provided on February 7, 2022. 
 
You asked the Plan to waive the copayment for ER visit. You say that you were only trying to set up a PEER-
to-PEER talk and were told you wouldn't have to pay the ER copayment for that. The Plan denied your request. 
The Plan said you did speak with another doctor and had laboratory services done as well as an ultrasound. The 
Plan says the copayment applied is correct. 
 
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 $90 
copayment per emergency department visit.  
 
You have been asked to pay $90 copayment for ER visit. ER visits fall within the Emergency Care benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for ER visit provided on February 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a brain MRI to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a brain MRI to be provided by an OON provider. You say that you would 
like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 
neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network providers available 
to the enrollee that can provide the services being requested. 
 
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 brain MRI to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72170 billed for date of service March 30, 
2022. 
 
  You asked the Plan to pay for procedure code 72170. You say that the enrollee had multiple exams on this date 
of service and the attached reports support this level of service. You say that the claim should be reconsidered 
for processing. The Plan denied your request. The Plan says payment for code 72170 is bundled into payment 
for code 73502. 
 
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 72170 
is a column II code to column I code 73502. 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 72170 billed for date of service March 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on February 
22, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that your dialysis services 
should be covered in full. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $35 
copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse 
practitioner or physicians assistant or other non-physician health care professionals in a specialists office (as 
permitted under Medicare rules). 
 
 
 You have been asked to pay $35 copayment for specialist office visit. Specialist office visits fall within the 
Physician/Practitioner Services, Including Doctors Office Visits 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 specialist office visit provided on February 22, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 16 physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the PT visits. You say that treatment is medically necessary for the enrollee 
to provide pain relief and decreasing his risk for falls. The Plan denied your request. The Plan says notes do not 
show that ongoing services will result in the practical improvement in the enrollee's level of function within a 
reasonable period of time. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 PT visits. Our reviewer says that skilled 
services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. 
Our physician reviewer found that the enrollee has had prior therapy and documentation does not reveal that 
the enrollee requires the unique skills of a professional therapist to provide treatment safely and effectively, 
that the services can be safely and effectively performed only by a therapist, or under the supervision of a 
therapist.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PT visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 16 physical therapy (PT) visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgical services provided on 
January 19, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgical services. You say that you already paid a 
$250 copayment you shouldn't have to pay any more. The Plan denied your request. The Plan says the 
copayment applied is correct. 
 
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 $250 
copayment for each Medicare-covered ambulatory surgical center visit.  
 
You have been asked to pay $250 copayment for outpatient surgical services. Outpatient surgical services 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 outpatient surgical 
services provided on January 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided on 
September 30, 2020. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that this stay should be covered 
in full. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $250 copayment for each Medicare covered hospital stay until discharge.  
 
The enrollee has been asked to pay $250 copayment for inpatient hospital stay. Inpatient hospital stay falls 
within the Inpatient Hospital Care benefit category. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for inpatient hospital stay provided on September 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drug provided in an outpatient setting 
on April 14, 2022. 
 
You asked the Plan to pay for the self-administered drug. You say that this was not a self-administered drug. 
You say that you were sedated during this procedure. You also say that you could not have self-administered 
the drug The Plan denied your request. The Plan says the drug you received in an outpatient setting is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D 
prescription drug plan. The Plan also says the drug is not covered under Medicare Part B. 
 
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 pay for the self-administered drug 
provided in an outpatient setting on April 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for in office scrape biopsy provided on April 
11, 2022. 
 
You asked the Plan to waive the copayment for in office scrape biopsy. You say that this was done in office not 
in an operating room so you shouldn't be charged a surgical copayment. The Plan denied your request. The 
Plan says the copayment applied is correct. 
 
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 $250 
copayment per visit for surgical services.  
 
You have been asked to pay $179.15 which is less than the standard $250 copayment for in office scrape 
biopsy. In office scrape biopsys fall 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 in office scrape biopsy provided on April 11, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on August 18, 
2021. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you should not be responsible 
for this cost share. The Plan denied your request. The Plan says the cost share 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 $20 
copayment for Medicare-covered physical therapy visits.  
 
You have been asked to pay $20 for physical therapy. Physical therapy falls within the Outpatient 
Rehabilitation 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 physical therapy provided on August 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and acellular pertussis 
vaccine (Tdap) (90715) and administration (90471) provided on April 5, 2022. 
 
You asked the Plan to pay for the T-dap vaccine. You say that you had no idea that the vaccine would not be 
covered. The Plan denied your request. The Plan says the Tdap vaccine is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that vaccinations or inoculations are excluded as 
immunizations unless they are directly related to the treatment of an injury or direct exposure to a disease or 
condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the T-dap vaccine have not been met. Therefore, we decided that the Plan does not have to pay for 
the Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) (90715) and administration (90471) 
provided on April 5, 2022.  
 Benefits for the T-dap vaccine 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on 
December 20, 2021. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that this should be covered. The 
Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $40 
copayment for each specialist visit for Medicare covered benefits.  
 
You have been asked to pay $34.47 which is less than the standard $40 copayment for specialist office visit. 
Specialist office visits fall within the Physician/ Practitioner Services, Including Doctors Office Visits 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 specialist office visit provided on December 20, 
2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on 
November 9, 2021. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you didn't call the 
ambulance yourself so you shouldn't have to pay for it. The Plan denied your request. The Plan says the 
copayment applied is correct. 
 
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 $250 
copayment for Medicare-covered ambulance services. Cost sharing applies for each one-way trip.  
 
 
 
 You have been asked to pay $245.78 which is less than the standard $250 copayment for ambulance transport. 
Ambulance transport 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 transport provided on November 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out of network surgical services provided 
on June 30, 2021. 
 
You asked the Plan to waive the coinsurance for out of network surgical services. You say that you had been 
approved to see someone out of network. The Plan denied your request. The Plan says the coinsurance applied 
is correct. 
 
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 40% 
coinsurance of the total cost for Medicare covered outpatient hospital services.  
 
You have been asked to pay $805.47 which is 40% of the total cost for out of network surgical services. Out of 
network surgical services falls within the Outpatient Surgery, Including Services provided at Outpatient 
Hospital 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 
coinsurance for out of network surgical services provided on June 30, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF care provided from February 8, 2022, 
to February 28, 2022. 
 
You asked the Plan to waive the copayment for SNF care. You say that this was medically necessary for the 
enrollee so it should be covered. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $0 copayment per day for days 1 through 20 and $188 copayment per day for days 21 through 100.  
 
The enrollee has been asked to pay $188 copayment for SNF care. SNF care falls within the Skilled Nursing 
Facility (SNF) Care benefit category. This means that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for SNF 
care provided from February 8, 2022, to February 28, 2022.