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

 
We decided that the Plan does not have to waive the copayment for ambulance services you received on 
September 2, 2021. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you were just transported 
a short distance.  You said that had you known about the charge, you would have had a friend take you instead. 
The Plan denied your request. The Plan says you were charged this copayment 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 $200 
copayment for ambulance services.  
 
You have been asked to pay a $200 copayment for the ambulance services. This copayment applies regardless 
of the distance of the transport. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services you 
received on September 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for eyeglasses provided on  
September 9, 2021. 
 
You asked the Plan to pay an additional amount for the eyeglasses. The Plan denied your request. The Plan 
says your annual eyewear allowance of $200 was applied to the total cost. 
 Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that your annual eyewear allowance of $200 was 
applied to the cost of the eyeglasses. Therefore, we decided that the Plan does not have to pay an additional 
amount for eyeglasses provided on September 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on September 10, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that the services should be covered in full 
as you have never been charged for these services before. The Plan denied your request. The Plan says the cost-
share applied correctly based on the services 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 $150 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
 
 
 You have been asked to pay a $150 copayment for a CT scan. CT scans 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 a computed tomography (CT) scan provided on September 10, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the sigmoidoscopy with mass removal and 
biopsy you had at an ambulatory surgery center on March 31, 2021. 
 
You asked the Plan to waive the copayment for the sigmoidoscopy. You say that this was a colorectal 
screening, so there should be no copayment. The Plan denied your request. The Plan says you were charged 
this copayment 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 $225 
copayment for outpatient surgery.   
You have been asked to pay a $225 copayment for the sigmoidoscopy. Your contract says that when a 
screening sigmoidoscopy becomes a diagnostic procedure (e.g., results in a biopsy or removal or a lesion or 
growth), then outpatient surgery cost sharing applies. That was the case here- you had a mass removed and sent 
for biopsy. That is why the sigmoidoscopy falls within the outpatient surgery 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 sigmoidoscopy with mass removal and biopsy you had at an 
ambulatory surgery center on March 31, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for selective catheter placement provided to the enrollee on May 7, 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 that this service is not supported without the required documentation. 
 
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, the CPT Code Manual definition of 
code 36215 is "Selective catheter placement, arterial system; each first order thoracic or brachiocephalic 
branch, within a vascular family." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found coding for fistula angiography is bundled 
to include the circuit from the arterial anastomosis through the vena cava. Selective access of the inflow artery 
to evaluate the inflow and to potentially perform formal upper extremity angiography, is coded with 36215, 
addressing the work performed by placing the catheter within the inflow artery. As there is specific 
documentation that the brachial artery was catheterized, code 36215 is the code used to signify this work. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
selective catheter placement provided to the enrollee on May 7, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $10 copayment for a PCP office visit provided on 
September 17, 2021. 
 
You asked the Plan to waive the $10 copayment for the office visit. You say that this was an annual physical 
and you were expecting it to 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 a $10 
copayment for each covered office visit with your PCP.  
 
 You have been asked to pay a $10 copayment for an office visit. 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 $10 copayment for a PCP office visit provided on September 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for pegfilgrastim injections the enrollee 
received from September 20, 2021, to November 1, 2021. 
 
You asked the Plan to waive the coinsurance for the pegfilgrastim injections. You say that you thought this was 
going to be completely covered. The Plan denied your request. The Plan says this coinsurance was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay 20% coinsurance for Medicare Part B drugs.  
 
The enrollee has been asked to pay 20% coinsurance for the pegfilgrastim injections. The pegfilgrastim 
injections fall within the Medicare Part B 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 upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive 
the coinsurance for pegfilgrastim injections the enrollee received from September 20, 2021, to November 1, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an at home sleep study provided on 
November 11, 2021. 
 
You asked the Plan to waive the copayment for the at home sleep study. You say that the services should be 
covered in full. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the 
services 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 $10 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
 
 
 You have been asked to pay a $10 copayment for an at home sleep study. Sleep studies 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 an at home sleep study provided on November 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the home ventilator you received on 
September 16, 2021. 
 
You asked the Plan to waive the coinsurance for the home ventilator. You say that the price of this item is very 
high. The Plan denied your request. The Plan says you were charged this coinsurance correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay 20% coinsurance for the home ventilator. The home ventilator falls within the 
durable medical equipment 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 home 
ventilator you received on September 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the primary care office visit you had on 
October 7, 2021. 
 
You asked the Plan to waive the coinsurance for the primary care office visit. You say that this was your annual 
wellness visit, so there should be no copayment. The Plan denied your request. The Plan says you had both an 
annual wellness visit and a regular office visit on this date of service.  The Plan says that you were not charged 
anything for the annual wellness portion of the visit. Rather, you are only responsible for coinsurance for the 
office visit portion of this visit. 
 
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 10% 
coinsurance for primary care visits.   
According to your contract, annual wellness visits and routine physical exams do not have cost sharing.  
However, these visit types only include limited services.  In this case, the records indicate that in addition to an 
annual wellness visit, you received an office visit that extended beyond the scope of what is part of an annual 
wellness visit or routine physical.  According to the billing records, you were also seen for hyperlipidemia, 
vitamin D deficiency, hypothyroidism, and pre-diabetes.  Evaluation for these conditions is not part of a 
wellness visit or routine physical, which is why the regular primary care cost sharing applies. You have been 
asked to pay 10% coinsurance for the primary care office 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. Please note that you are only responsible for the $13.88 coinsurance for this 
date of servicethe Plan has confirmed that you are not responsible for other charges on this date of service 
with this provider. Therefore, we decided that the Plan does not have to waive the coinsurance for the primary 
care office visit you had on October 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 29, 
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 this service should not be unbundled. 
 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 October 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that the enrollee is disabled and incontinent. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electromyography (procedure code 95870) provided to the 
enrollee on May 4, 2021. 
 You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says a valid diagnosis was not billed in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the EMG in this case was not done directly for diagnostic purposes. It was done simply for monitoring.  
This does not reflect an indication for which said testing is otherwise covered. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for electromyography (procedure code 95870) provided to the enrollee on May 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for eyeglasses provided on  
October 12, 2021. 
 You asked the Plan to pay an additional amount for the eyeglasses. The Plan denied your request. The Plan 
says the benefit of $250 allowance was applied to the purchase, leaving you with a responsibility of $209, 
which was paid at the time of purchase. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services with a $250 allowance. 
 
We looked at the file and the Plan's rules. The file shows that the Plan has paid the maximum eyewear 
allowance of $250. Therefore, we decided that the Plan does not have to pay an additional amount for 
eyeglasses provided on October 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the 20% coinsurance for the Medicare-covered Part B drug 
injection provided on October 18, 2021. 
 
You asked the Plan to waive the 20% coinsurance for the Medicare-covered Part B drug injection. You say that 
you disagree with the 20% coinsurance amount charged and that you only should owe a $25 copayment. The 
Plan denied your request. The Plan says the amount charged 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 20% 
coinsurance for Medicare-covered Part B drugs and a $25 copayment for administration of Part B drugs by a 
specialist.  
 
You have been asked to pay $401.76, which is 20% of the allowed amount ($2,008.80) for the Medicare-
covered Part B drug injection provided on October 18, 2021. The $25 copayment is an additional charge for the 
administration of the drug, totaling your cost to $426.76. Medicare-covered Part B drug injections fall 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 20% 
coinsurance for the Medicare-covered Part B drug injection provided on October 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan of lower extremity arteries or arterial bypass 
grafts (93925) provided on July 3, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a duplex scan of lower extremity arteries or arterial bypass grafts. You say that 
you disagree with the Plan's decision that the services were not medically necessary. The Plan denied your 
request. The Plan says this provider is a non-network provider with the Plan and another non-network provider 
with the Plan referred the member for services. The Plan also says there was no necessity for an out-of-network 
provider, such as an urgent or emergency situation that has been determined. 
 
 
 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 duplex scan of lower extremity arteries or 
arterial bypass grafts (93925) provided on July 3, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Emgality. 
 
You asked the Plan to pre-approve Emgality. You say that the enrollee has worsening clusters. The Plan denied 
your request. The Plan says the drug is not eligible for coverage under the Part B 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 Emgality.  
 
 
 Benefits for Emgality 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from October 9, 2021, 
through October 15, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that an 
inpatient admission was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the review indicates that the record showed that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollees necessary hospital care (including earlier emergency room 
and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from October 9, 2021, through October 15, 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.