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

 
We decided that the Plan does not have to pre-approve Mexiletine. 
 
You asked the Plan to pre-approve Mexiletine. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Mexiletine.  
 
Benefits for Mexiletine 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry 
(83789) provided on March 29, 2022. 
 
You asked the Plan to pay for procedure code 83789. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 83789 have not been met. Specifically, we find that the testing described by the 
billed code is considered specimen validity testing which is not separately payable. Therefore, we decided that 
the Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry (83789) provided on 
March 29, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiological diagnostic services provided 
on April 20, 2022. 
 
You asked the Plan to waive the copayment for radiological diagnostic services. You say that this was a 
required test so it should be covered. The Plan denied your request. The Plan says this cost sharing 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). Your contract with the Plan clearly says that you must pay a 
$103.58 copayment for radiological diagnostic services. 
 
You have been asked to pay a $103.58 copayment for radiological diagnostic services. This item/service falls 
within the radiological diagnostic 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 radiological diagnostic services provided on April 20, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a duplex scan ultrasound provided on 
December 08, 2021. 
 
You asked the Plan to waive the copayment for a duplex scan ultrasound. You say that you had this scan done 
while your were inpatient, it should not have a copayment. The Plan denied your request. The Plan says this 
cost sharing 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). Your contract with the Plan clearly says that you must pay a $105 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $105 copayment for a duplex scan ultrasound. This item/service 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 a duplex scan ultrasound provided on December 08, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cataract surgery provided on April 27, 
2022. 
 
You asked the Plan to waive the copayment for a cataract surgery. You say that you dont think its fair that you 
have to pay a copayment a second time. The Plan denied your request. The Plan says this cost sharing 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). Your contract with the Plan clearly says that you must pay a $350 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $350 copayment for a cataract surgery. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.  Therefore, we decided that the Plan does not have to waive the copayment for a cataract surgery provided on 
April 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) on tooth #18 on April 27, 2022. 
 
You asked the Plan to pay for the crown (D2740) on tooth #18. You say that you were diagnosed with visible 
mesial and distal cracks with active decay within the mesial crack. You say your dentist's treatment for the 
tooth was a full coverage crown to protect the integrity of the remaining tooth structure. The Plan denied your 
request. The Plan says the service is only covered when the tooth is extensively decayed and/or fractured and 
cannot be restored with a direct restoration.  The service did not meet coverage criteria. 
 
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. The Plan covers the crown 
(D2740) on tooth #18 when the services are medically necessary and reasonable.  
 
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 crown (D2740) on tooth #18. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the x-ray of tooth #18 
shows an existing occlusal restoration and possible incipient or small mesial caries. In this instance, only 15% 
of the tooth structure is decayed. The record shows that there does not appear to be sufficient missing structure 
in order to require a full coverage crown to restore the tooth and maintain it in function.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown (D2740) on tooth #18 have not been met. Therefore, we decided that 
the Plan does not have to pay for the crown (D2740) on tooth #18 on April 27, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospice services provided to the enrollee on November 15, 
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 patient was enrolled in the federal hospice program. 
 
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 hospice services provided to the enrollee on November 15, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for Part B drugs, medical supplies and 
outpatient observation on January 14, 2022. 
 
You asked the Plan to waive the cost sharing for Part B drugs, medical supplies and outpatient observation. 
You say that you want to appeal the amount being charged. The Plan denied your request. The Plan says this 
cost sharing 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). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for all other Medicare-covered Part B drugs. Covered drugs include Drugs that usually arent self-
administered by the patient and are injected or infused while you are getting physician, hospital outpatient, or 
ambulatory surgical center services. You must pay a 20% coinsurance for each Medicare-covered medical 
supply. Covered services include, but are not limited to surgical supplies, such as dressings. You must pay a 
$250 copayment for each day of Medicare-covered observation services provided to you at an outpatient 
hospital, including but not limited to hospital or other facility charges and physician or surgical charges. The 
provider billed in the amount of $260 and the allowed amount is $130. This is less than the copayment amount. 
The provider billed in the amount of $42.50 and the allowed amount is $21.25. $21.25 x 20% = $4.25. The 
provider also billed in the amount of $45.60 and the allowed amount is $22.80. $22.80 x 20% = $4.56. $130 + 
$4.25 + $4.56 = $138.81. Therefore, results in the total cost sharing amount of $138.81. 
 
You have been asked to pay a 20% coinsurance for Part B drugs, 20% coinsurance for medical supplies and 
$130 copayment, which is less than the copayment for outpatient observation. This item/service falls within the 
Medicare Part B prescription drugs and Outpatient diagnostic tests and therapeutic services and supplies and 
Outpatient surgery and other medical 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 cost sharing for Part B drugs, medical supplies 
and outpatient observation on January 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a diagnostic injection provided on June 29, 
2022. 
 
You asked the Plan to reduce the copayment for a diagnostic injection. You say that you should only have a 
$35 copayment for these injections, not $245. The Plan denied your request. The Plan says this cost sharing 
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). Your contract with the Plan clearly says that you must pay a $245 
copayment for outpatient hospital services. 
 
You have been asked to pay a $245 copayment for a diagnostic injection. This item/service falls within the 
outpatient hospital 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 reduce the copayment for a 
diagnostic injection provided on June 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) 
billed for date of service January 3, 2022. 
 
You asked the Plan to pay for mass spectrometry services. You say that this service was necessary and is 
supported as billed. The Plan denied your request. The Plan says this service is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of mass spectrometry services have not been met. Specifically, we find that the testing described by 
the billed code is considered specimen validity testing which is not separately payable. Therefore, we decided 
that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) billed for date 
of service January 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (88305) provided on January 19, 2022. 
 
You asked the Plan to pay for procedure code 88305. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered 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. 
 
We looked at the file and the rules. We find that the code was not billed with a modifier suitable for payment. 
Based on this information, we decided that Medicare rules for coverage of procedure code 88305 have not been 
met. Therefore, we decided that the Plan does not have to pay for the laboratory service (88305) provided on 
January 19, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that You say that the VA 
usually covers copayments like this, and you should not have to pay. 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 $275 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $275 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 8, 2022, billed with 
codes 81225, 81227, 81230, 81231, 81232, 81291, 81306, 81328, 81355, 81335, 0031U, 0032U, 0033U, 
81479, 81407, 81406, and 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 8, 2022, billed with codes 81225, 81227, 81230, 81231, 81232, 81291, 81306, 81328, 81355, 81335, 
0031U, 0032U, 0033U, 81479, 81407, 81406, and 81238.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 88342 billed for date of service September 
15, 2021. 
 
You asked the Plan to pay for procedure code 88342. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 88342 is bundled into payment for code 88189. 
 
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 88342 
is a column II code to column I code 88189. 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 88342 billed for date of service September 15, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on April 25, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on April 
25, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
September 09, 2021. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you were not informed 
of any costs for the service. The Plan denied your request. The Plan says this cost sharing 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). Your contract with the Plan clearly says that you must pay a $120 
copayment for emergency services. 
 
You have been asked to pay a $120 copayment for the emergency room visit. This item/service falls within the 
emergency services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan.  Therefore, we decided that the Plan does not have to waive the copayment for the emergency room 
visit provided on September 09, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for office visits, injections and radiology 
services provided on August 25, 2021, and November 22, 2021. 
 
You asked the Plan to waive the cost share for office visits, injections, and radiology services. You say that you 
dont understand why you have to pay so much. The Plan denied your request. The Plan says this cost sharing 
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). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B covered drugs, $160 copayment for radiology services and $35 copayment for specialist visits. 
 
You have been asked to pay a total of $1,565 for office visits, injections, and radiology services. This 
item/service falls within the Medicare Part B Prescription Drugs, Medicare-covered radiological diagnostic 
services, and specialist 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 cost share for 
office visits, injections and radiology services provided on August 25, 2021, and November 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a specialist office visit and injection 
provided on May 16, 2022. 
 
You asked the Plan to waive the cost share for a specialist office visit and injection. You say that you were told 
this would be covered in full. The Plan denied your request. The Plan says this cost sharing 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). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B covered drugs and a $15 copayment for all specialist visits.  
 
 
 
 You have been asked to pay $15.18 for a specialist office visit and injection. This item/service falls within the 
Medicare Part B prescription drugs benefit category and the provider and professional services 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 cost share for a specialist office visit and 
injection provided on May 16, 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 April 
28, 2022, to May 03, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you shouldnt have to pay 
for this. The Plan denied your request. The Plan says this cost sharing 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). Your contract with the Plan clearly says that you must pay a $750 
copayment for inpatient hospital care. 
 
You have been asked to pay a $750 copayment for inpatient hospital stay. This item/service falls within the 
inpatient hospital 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 inpatient 
hospital stay provided on April 28, 2022, to May 03, 2022.