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

 
We decided that the Plan does not have to waive the copayments for wound care services provided from 
November 4, 2021, to November 24, 2021. 
 
You asked the Plan to waive the copayments for the wound care. You say that no procedures were performed, 
only dressing changes. 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 visit for outpatient surgery or procedures at a hospital facility.  
 
You have been asked to pay a $225 copayment per visit for the four wound care visits. The total for the visits is 
$900 ($225 copayment x 4 visits = $900). The wound care 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 copayments for wound care services provided from November 4, 2021, to 
November 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
August 4, 2021, to August 12, 2021.  
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that your $3,600 out-of-
pocket maximum was already met. 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 $295 
copayment per day for days 1-5 for an inpatient hospital stay. The contract says there is no additional 
copayment after day 5. The Plans contract also says that there is a $3,600 maximum out-of-pocket (MOOP) 
per calendar year. 
 The record shows this claim was applied to your MOOP, which had not been met at the time the claim was 
processed. You have been asked to pay a total of $458.40, which is less than the $295 copayment per day for 
days 1-5 of an inpatient hospital stay. An inpatient hospital stay 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 an inpatient hospital stay provided from August 
4, 2021, to August 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for wound care services provided from 
October 14, 2021, to October 28, 2021. 
 
You asked the Plan to waive the copayments for the wound care. You say that no procedures were performed, 
only dressing changes. 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 visit for outpatient surgery or procedures at a hospital facility.  
 
You have been asked to pay a $225 copayment per visit for the wound care. The total for the three visits is 
$675 ($225 copayment x 3 visits = $675). The wound care 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 copayments for wound care services provided from October 14, 2021, to 
October 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy administration provided 
from November 10, 2021, to November 24, 2021.  
 
You asked the Plan to waive the coinsurance for chemotherapy administration. You say that you were unaware 
you would have to pay these charges. 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 20% 
coinsurance for chemotherapy administration.  
 You have been asked to pay 20% coinsurance for chemotherapy administration from November 10, 2021, to 
November 24, 2021. Chemotherapy administration falls within the Medicare Part B Prescription Drug benefit 
category.  
 
Date of Service Code Allowed Amount 20% Coinsurance 
November 10, 2021 96413 $283.29 $56.66 
November 10, 2021 96417 $136.85 $27.37 
Claim Total   $84.03 
November 17, 2021 96413 $283.29 $56.66 
November 17, 2021 96417 $136.85 $27.37 
Claim Total   $84.03 
November 24, 2021 96413 $283.29 $56.66 
November 24, 2021 96417 $273.70 $54.74 
Claim Total   $111.40 
 
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 chemotherapy administration provided from November 10, 
2021, to November 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81479) provided January 27, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 genetic testing (81479) provided 
January 27, 2022 have been met. No clinical records were provided to support the testing. Provided 
documentation was limited to lab results and medical literature. Therefore, we decided that the Plan does not 
have to pay for genetic testing (81479) provided January 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 10, 2021. 
 
You asked the Plan to pay for the laboratory services. 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 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 laboratory 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 the laboratory services provided on February 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services coded as 80307 provided on 
December 13, 2021. 
 
You asked the Plan to pay for code 80307. 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 Medicare rules. In this case, the Plan has made payment for one unit of CPT code 80307. According to Medicare rules, only one code may be reported from the range 80305-80307 per date of 
service. Based on this information, we decided that Medicare rules for coverage of code 80307 have not been 
met. Therefore, we decided that the Plan does not have to pay for the drug testing services coded as 80307 
provided on December 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 13, 2021. 
 
You asked the Plan to pay for the laboratory services. 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 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 laboratory 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 the laboratory services provided on January 13, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a mental health office visit provided on 
December 13, 2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that you were billed for services that 
were not completed. 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 each therapy visit.  
 
The record shows that mental health services were provided on December 13, 2021. Therefore, you have been 
asked to pay a $35 copayment for the office visit. The office visit falls within the Outpatient Mental Health 
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 a mental health office visit 
provided on December 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hearing aids provided on November 11, 2021. 
 
You asked the Plan to reimburse you for hearing aids. The Plan denied your request. The Plan says you must 
use the Plans hearing provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use the Plans hearing provider. 
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plans 
hearing provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have 
not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on 
November 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cataract surgery provided on April 20, 
2021. 
 
You asked the Plan to waive the copayment for cataract surgery. You say that you paid upfront before surgery 
for special lens, and you asked if everything was paid, which you were told it was. 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 outpatient surgery at an ambulatory surgical center.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$225 copayment for cataract surgery. Cataract surgery 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 cataract surgery provided on April 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cytopathology services (88177) provided on October 25, 
2021. 
 
You asked the Plan to pay for code 88177. 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. In this case, we have confirmed that code 88177 
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for the Cytopathology services (88177) provided on October 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for personal care services provided from March 15, 2022, 
through March 29, 2022. 
 
You asked the Plan to pay for personal care services. The Plan denied your request. The Plan says personal care 
services are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of personal care services have not been met. Specifically, we find that the services at issue in this case 
are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for personal care 
services provided from March 15, 2022, through March 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy services. 
 
You asked the Plan to pre-approve massage therapy services. You say that this is medically necessary. The 
Plan denied your request. The Plan says massage therapy services are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 testing kit provided on January 2, 
2022. 
 
You asked the Plan to pay for the at-home COVID-19 testing kit. 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. 
 
The Plan must follow Medicare rules. CMS says that Plans and insurers are required to cover at-home over the 
counter COVID-19 tests purchased on or after January 15, 2022. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the at-home COVID-19 testing kit have not been met. Specifically, the at-home COVID-19 testing 
kit was purchased before the date of January 15, 2022. Therefore, we decided that the Plan does not have to pay 
for the at-home COVID-19 testing kit provided on January 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cimzia. 
 
You asked the Plan to pre-approve Cimzia. You say that the enrollee has been on Cimzia since 2012, and her 
Rheumatoid Arthritis (RA) has been under great control. You also say that there is no medical indication to 
change the enrollee's RA treatment, and it is your medical opinion that the enrollee should stay on Cimzia. The 
Plan denied your request. The Plan says Cimzia is a benefit exclusion. 
 
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 Cimzia.  
 
Benefits for Cimzia 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: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on October 30, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the laboratory services by a contract provider. The file does not show that the 
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on October 30, 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 copayment for a specialist office visit provided on 
December 29, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you went to this 
appointment thinking you would be getting nutritional help. You also say there is a $0 copayment for medical 
nutrition. 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 $45 
copayment for a specialist office visit. The Plan contract also says that nutrition and weight management 
services are offered by registered dieticians in the form of nutrition counseling (non-diabetes) and weight 
management courses. 
 The Plan confirmed the provider you had seen during your visit on December 29, 2021, is not a registered 
dietitian. You have been asked to pay a $45 copayment for a specialist office visit. A specialist office visit falls 
within the Physician/Practitioner Services, Including Doctors Office Visits benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a specialist office visit provided on December 29, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on August 10, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the laboratory services by a contract provider. The file does not show that the Plan 
provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the Plan. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on August 10, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic examination (71046) provided on October 13, 
2021. 
 
You asked the Plan to pay for code 71016. 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. 
 
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 confirm that Medicare 
coverage criteria have been met. 
 
We looked at the file and Medicare rules. In this case, there were no medical records provided confirming that 
two separate x-rays were provided on October 13, 2021. The file shows that the Plan paid for one x-ray (1 unit of 71046-26) provided on October 13, 2021. Therefore, we decided that the Plan does not have to pay for the 
radiologic examination (71046) provided on October 13, 2021.