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

 
We decided that the Plan does not have to waive the deductible for a transthoracic echocardiogram (TTE) with 
doppler provided on October 5, 2021. 
 
You asked the Plan to waive the deductible for the TTE with doppler. You say that you cannot afford the bill. 
The Plan denied your request. The Plan says the correct amount was applied to your deductible. 
 
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 $500 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $500 deductible which applies to certain items and services. This cost 
sharing is a contractual obligation that had not been met at the time the TTE with doppler was received on 
October 5, 2021. Therefore, we decided that the Plan does not have to waive the deductible for a transthoracic 
echocardiogram (TTE) with doppler provided on October 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 4, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and deductible for Ambulatory Surgery on 
May 7, 2021. 
 
You asked the Plan to waive the copayment and deductible for Ambulatory Surgery. You say that you do not 
feel you should owe the full amount of the bill, because this is the most you have had to pay out of pocket for 
this provider. The Plan denied your request. The Plan says their review determined the member has not met the 
minimum $800 deductible amount and the claim is processed correctly. The allowed amount of this surgery is 
$1,350, resulting in a copayment amount of $185.37 and a deductible of $800. 
 
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 $450 copayment and an $800 deductible which applies to Ambulatory 
Surgery. At the time this claim was processed, $0 of the $800 deductible had been met. The allowed amount of 
the claim is $985.37, resulting in a deductible amount of $800. After the deductible is met the remaining 
allowed amount of the claim is $185.37, resulting in a copayment amount of $185.37 because this is less than 
the $450 copayment for ambulatory surgery. Therefore, your total cost-sharing amount is $985.37. 
 The item or service you asked the Plan to waive the copayment and deductible for falls within the Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $450 
copayment and an $800 deductible which applies to Ambulatory Surgery. This cost sharing is a contractual 
obligation that had not been met at the time Ambulatory Surgery was received on May 7, 2021. Therefore, we 
decided that the Plan does not have to waive the copayment and deductible for Ambulatory Surgery on May 7, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Neulasta Onpro. 
 
You asked the Plan to pre-approve Neulasta Onpro. You say that the enrollee is receiving chemotherapy 
treatments and needs extra help keeping blood cell counts up. The Plan denied your request. The Plan says the 
denial of authorization for this drug is correct, because the enrollee is receiving a low-risk treatment regimen. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Neulasta Onpro. Our reviewer says that 
the enrollee does not meet the Medicare criteria for the requested use of Neulasta Onpro. Our physician 
reviewer found gemcitabine is low-risk and given recurrent disease, dose reduction is the preferred option. 
Neulasta Onpro is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. The requested 
use is not supported by one of the major drug compendia or by clinical research appearing in a Medicare-
approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Neulasta Onpro have not been met. Therefore, we decided that the Plan does 
not have to pre-approve use of Neulasta Onpro.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on May 23, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the procedure was not billed with an allowed modifier. 
 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 70450 
is a column II code to column I code 70496. 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 imaging services provided to the enrollee on May 23, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided 
September 24, 2021 to September 25, 2021. 
 You asked the Plan to pay for the SNF services. You say that you feel that the Plan should cover for the SNF 
services provided. The Plan denied your request. The Plan says medical necessity cannot be established for 
SNF level of coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily 
basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility setting. 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for the skilled nursing facility (SNF) services provided September 24, 2021 to September 25, 
2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional hours for a home health aide (6 hours a day, 7 
days a week). 
 
You asked the Plan to pre-approve the additional hours. You say that this is medically necessary. The Plan 
denied your request. The Plan says this can be approved for four hours a day, 7 days a week. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 the additional hours. Our reviewer says 
that the requested additional hours are not medically reasonable or necessary. Our physician reviewer found the 
provided records do not document why the 4 hours per day for 7 days per week as approved by the health plan 
are inadequate to meet your needs.  
 There is inadequate documentation that home health aide services 6 hours per day for 7 days per week are 
reasonable and necessary (as opposed to home health aide services 4 hours per day for 7 days per week) as 
defined by Medicare criteria. 
 
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 additional hours have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional hours for a home health aide (6 hours a day, 7 days a week).
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for psychotherapy (90832) provided on October 14, 2021. 
 
You asked the Plan to pay for the psychotherapy (90832). You say that supporting documentation is attached to 
process this claim. The Plan denied your request. The Plan says that the provider must attempt to consult the 
attending or primary care physician about the services. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. The only exception 
to the consultation requirement is in cases where the patient's primary care or attending physician refers the 
patient to the CP or LCSW. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy (90832) have been met. Specifically, the claim form support that the enrollee 
was referred to this provider by a primary physician. Therefore, we decided that the Plan has to pay for 
psychotherapy (90832) provided on October 14, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 5, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
 
 
 
 We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on October 5, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for emergency room (ER) visits provided 
from November 6, 2021, to November 20, 2021. 
 
You asked the Plan to waive the copayments for the ER visits. You say that you were informed by Plan 
representatives that there would be no ER charges for the remaining shots. 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 $120 
copayment for each emergency room visit.  
 
The file shows you had ER visits on November 6, 2021, November 7, 2021, November 9, 2021, and November 
20, 2021. Therefore, you have been asked to pay a $120 copayment for each of the ER visits. The total for all 4 
visits is $480. The 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 copayments for emergency room (ER) visits provided from November 6, 2021, to November 20, 
2021.  
 
Your complaint about Plan representatives giving misinformation about the cost sharing is not a valid appeal 
for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare 
does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on August 
6, 2021. 
 
You asked the Plan to waive the copayment for the lab services. You say that you disagree with the copay 
amount and would like the plan to reconsider. 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 $15.00 
copay for each covered lab service.  
 
 
 You have been asked to pay $15.00 copay for the lab services. The lab services fall 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 laboratory services provided on August 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and coinsurance for inpatient hospital services 
provided from July 13, 2021, to July 17, 2021. 
 
You asked the Plan to waive the deductible and coinsurance for the inpatient hospital services. You say that 
you were informed that the Plan would cover the remaining costs after Medicare payment. The Plan denied 
your request. The Plan says the correct coinsurance 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 says that there is a $250 deductible 
which applies to certain items and services. 
 
The enrollees contract with the Plan also clearly says that enrollees must pay a 20% coinsurance for each 
admission.  
 
Your contract with the Plan also clearly says that enrollees have a combined maximum out-of-pocket (MOOP) 
amount of $1,400. 
 
The item or service you asked the Plan to waive the deductible and coinsurance for falls within the Inpatient 
Hospital Care benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $250 deductible which applies to certain items and services. This cost sharing is a contractual 
obligation that had not been met at the time the inpatient hospital services were received from July 13, 2021, to 
July 17, 2021.  
 
The file shows the enrollee had $186.56 remaining to meet their deductible. This amount was applied first. The 
remaining amount is subject to the 20% coinsurance, which is $3,410.39 ($17,051.96 allowed amount x 20% 
coinsurance = $3,410.39. However, the enrollee only had a total of $1,125 remaining to meet their MOOP 
expenses, which is the remainder of the charges. The total for the stay is $1,311.56. Therefore, we decided that 
the Plan does not have to waive the deductible and coinsurance for inpatient hospital services provided from 
July 13, 2021, to July 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on June 24, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you do not agree with the denial. The Plan denied 
your request. The Plan says this service was not urgent, not authorized, not referred by the Plan provider, and 
the provider was not a Plan 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 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 an office visit (99214) provided on June 24, 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 the revision of eyelashes (67820) and the closure of a tear 
duct opening (68761) rendered by the out-of-network (OON) provider on April 12, 2021 and May 10, 2021. 
 
You asked the Plan to pay 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 the services were rendered by an out of 
network provider, without prior authorization. 
 
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 had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the revision of eyelashes (67820) and the closure of a tear duct opening (68761) 
rendered by the out-of-network (OON) provider on April 12, 2021 and May 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for basic life support, non-emergency transport 
ambulance services (A0999, A0428) and ground mileage (A0425) rendered on November 9, 2021. 
 
You asked the Plan to waive the copayment for basic life support, non-emergency transport ambulance services 
and ground mileage. You say that you were told that you would not be responsible for charges, and that your 
transfer would be fully covered. You also say that coverage by the ambulance service is noted on your property 
tax bill, and you have been informed that someone else is to pick up costs and charges for ambulance services 
deemed to be medically necessary. The Plan denied your request. The Plan says you were 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 $200 
copayment per trip, each way for ambulance services.  
 
You have been asked to pay a $200 copayment per trip, each way for basic life support, non-emergency 
transport ambulance services and ground mileage. basic life support, non-emergency transport ambulance 
services and ground mileage 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 basic life support, non-emergency transport ambulance services (A0999, A0428) 
and ground mileage (A0425) rendered on November 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 72265 and 62284 billed for date of service 
October 25, 2021. 
 
You asked the Plan to pay for procedure codes 72265 and 62284. You say that the patient had multiple exams 
on this date of service. The Plan denied your request. The Plan says these services are not separately payable as 
billed. 
 
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 codes 
72265 and 62284 are column II codes to column I codes 72132 and 72265. 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 codes 72265 and 62284 billed 
for date of service October 25, 2021.