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

 
We decided that the Plan does not have to waive the coinsurance for renal dialysis services on March 02, 2022, 
to March 30, 2022. 
 
You asked the Plan to waive the coinsurance for renal dialysis services. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says the cost sharing you are being charged 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 a 20% 
coinsurance for renal dialysis services at dialysis or outpatient hospital. Covered services include outpatient 
dialysis treatments (including dialysis treatments when temporarily out of the service area, as explained in 
Chapter 3). The provider billed in the amount of $4,095 and the Plan paid $3,276. $4,095 x 20% = $819.00. 
Therefore, results in the total cost sharing amount of $819.   
 
 
 You have been asked to pay a 20% coinsurance for renal dialysis services. Renal dialysis services fall within 
the Services to treat kidney disease 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 
renal dialysis services on March 02, 2022, to March 30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the denosumab injection provided on May 
12, 2022. 
 
You asked the Plan to waive the cost share for the denosumab injection. You say that this was the only 
injection you were charged for, and it must be some kind of coding error. The Plan denied your request. The 
Plan says you have been charged the correct cost sharing 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 20% 
coinsurance for each Part B drug.  
 
You have been asked to pay a 20% coinsurance for the denosumab injection for a total of $186.53 ($932.64 
allowed amount x 20% = $186.53). The denosumab injection falls within the Medicare Part B Prescription 
Drugs 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 cost share for the denosumab injection provided 
on May 12, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound of soft tissues of head and 
neck provided on March 3, 2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that the Medicare website lists a $0 
copay. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $125 
copayment for ultrasounds.  
 
You have been asked to pay the allowed amount of $121.46, which is less than the $125 copayment for the 
ultrasound. The ultrasound 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 the ultrasound of soft tissues of 
head and neck provided on March 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on March 9, 
2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this was billed correctly and 
should be paid. The Plan denied your request. The Plan says equipment used outside the home is not covered.  
You billed with Place of Service 24, which is an ambulatory surgical center. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal was billed for use outside of the home. You billed with Place of Service 24, 
which is a surgical facility.  Equipment used in a facility is not separately payable. Therefore, we decided that 
the Plan does not have to pay for the pneumatic compression device provided on March 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient procedure 
 
You asked the Plan to waive the copayment for an outpatient procedure. You say that you should not have a 
copayment this high. The Plan denied your request. The Plan says the copayment applied was 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 a $325 
copayment for same day outpatient surgery (Includes diagnostic scopes such as an endoscopy).  
 
You have been asked to pay a $325 copayment for an outpatient procedure. an outpatient procedure falls within 
the Same Day Outpatient Surgery (Includes Diagnostic Scopes Such as an Endoscopy) 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 outpatient procedure
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for ambulance transportation provided from 
December 23, 2021, to December 31, 2021. 
 
You asked the Plan to waive the copayments for the ambulance transportation. You say that the trips were only 
needed due to contracting COVID-19 and a fall while at the rehab facility. The Plan denied your request. The 
Plan says you have been charged the correct cost sharing 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 $225 
copayment for each one-way ground ambulance trip.  
 
You have been asked to pay a $225 copayment for each ambulance transportation, for a total of $450. The 
ambulance transportation 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 copayments for ambulance transportation provided from December 23, 2021, to December 31, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on December 9, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that you were the only provider allowed into the 
facility where the enrollee lived, and you would like the claim reprocessed for payment. The Plan denied your 
request. The Plan says the rendering provider is an OON provider and there was no approved authorization. 
Also, the service rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a home health visit provided on December 9, 
2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service January 1, 
2022 to January 28, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that this code was billed correctly and this 
service was medically necessary. The Plan denied your request. The Plan says the billed code is invalid for 
Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service January 1, 2022 to January 28, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs (A9270) provided January 15, 2022 
to January 27, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that this service should be covered. The 
Plan denied your request. The Plan says the drugs billed are self-administered and not eligible for coverage 
under the Part B medical 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. There is a $130 maximum allowable amount for this service. The maximum allowable amount was assessed. Therefore, we decided that the Plan does not have to pay for self-administered drugs 
(A9270) provided January 15, 2022 to January 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the observation care provided from March 
9, 2022, to March 10, 2022. 
 
You asked the Plan to waive the copayment for the observation care. You say that the staff was unable to 
diagnose the cause of your pain and you should not have to pay this copay. The Plan denied your request. The 
Plan says you have been charged the correct cost sharing 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 $225 
copayment per stay.  
 
You have been asked to pay a $225 copayment for the observation care. The observation care 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 
the observation care provided from March 9, 2022, to March 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the office visit (99212), chiropractic 
manipulative treatment (98940), low-level laser treatment (S8948), massage therapy (97124), and the 
ultrasound therapy (97035) provided on November 3, 2021 and November 8, 2021. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says you did not 
provide valid proof of payment for these services.  
 
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. However, the Plan offers supplemental coverage of 
one chiropractic initial evaluation per calendar year. 
 
We reviewed the case file and the Plans rules. Based on this information, we find that the services provided do 
not meet the Plans rules for coverage. Specifically, the record does not show that a referral was submitted by 
your primary care physician for the services provided in this case.  The Plans contract states that you must first obtain a referral from your primary care physician before 
obtaining chiropractic services. Low-level laser treatment, massage therapy, and ultrasound therapy are not 
listed as covered benefits under the Plans contractual policy. Additionally, you did not submit valid proof of 
payment for the services provided in this case. Therefore, we decided that the Plan does not have to issue 
reimbursement for the office visit (99212), chiropractic manipulative treatment (98940), low-level laser 
treatment (S8948), massage therapy (97124), and the ultrasound therapy (97035) provided on November 3, 
2021 and November 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on May 9, 
2022. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that a behavioral assessment was 
billed but that was not done at the visit. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing 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 $35 
copayment for specialist visits.  
 
The records show that a specialist visit was provided on May 9, 2022. Therefore, you have been asked to pay a 
$35 copayment for the specialist visit. The specialist visit falls within the Physician/Practitioner Services, 
Including Doctor's 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 a 
specialist office visit provided on May 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown for tooth #20. 
 
You asked the Plan to pre-approve a crown for tooth #20. You say that the services are necessary. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 3, 2022. Therefore, 
we decided that the Plan does not have to pre-approve a crown for tooth #20.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on December 30, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that you are the only provider allowed into the 
facility where the enrollee was at, and you would like the claim reprocessed for payment. The Plan denied your 
request. The Plan says the rendering provider is an OON provider and there was no approved authorization. 
Also, the service rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a home health visit provided on December 30, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on September 30, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy services. You say that you were unaware of the prior 
authorization requirement. The Plan denied your request. The Plan says unauthorized, non-plan 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 in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for psychotherapy services provided on September 30, 2021 by an 
out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance on May 27, 2022. 
 
You asked the Plan to waive the copayment for ambulance. You say that you should not have any copayments. 
You do not need to pay this $200. The Plan denied your request. The Plan says the cost sharing you are being 
charged 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 a $200 
copayment for each Medicare-covered ground ambulance service.  Covered ambulance services include fixed 
wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that can provide care only 
if they are furnished to a member whose medical condition is such that other means of transportation could 
endanger the persons health or if authorized by the plan. 
 
 
 
 
 You have been asked to pay a $200 copayment for ambulance. Ambulance 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 on May 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Contour Next monitor and test strips. 
 
You asked the Plan to pre-approve a Contour Next monitor and test strips. You say that the items are necessary. 
The Plan denied your request. The Plan says medical records were not provided. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a Contour Next monitor and test strips 
have been met. Specifically, medical records were not provided. Medical necessity cannot be established 
without this documentation. Therefore, we decided that the Plan does not have to pre-approve a Contour Next 
monitor and test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for colonoscopy on February 24, 2022. 
 
You asked the Plan to waive the copayment for colonoscopy. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says the cost sharing you are being charged 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 a $300 
copayment for all other outpatient services not provided in an ambulatory surgical center. If you are having 
surgery in a hospital facility, you should check with your provider about whether you will be an inpatient or 
outpatient. Unless the provider writes an order to admit you as an inpatient to the hospital, you are an outpatient 
and pay the cost sharing amounts for outpatient surgery. Even if you stay in the hospital overnight, you might 
still be considered an outpatient. 
 
 
 You have been asked to pay a $300 copayment for colonoscopy. Colonoscopy 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 colonoscopy on February 24, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on April 25, 2022 
 
You asked the Plan to waive the copayment for an ultrasound. You say that the plan should have covered this 
cost. The Plan denied your request. The Plan says the copayment applied was 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 a $125 
copayment for other outpatient diagnostic tests.  
 
You have been asked to pay a $125 copayment for an ultrasound. an ultrasound falls within the Other 
Outpatient Diagnostic Tests Radiological Diagnostic Services, Not Including X-Rays 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 ultrasound provided on April 25, 2022.