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

 
We decided that the Plan does not have to pay for a self-administered drug provided from February 11, 2022, to 
February 13, 2022. 
 
You asked the Plan to pay for a self-administered drug. The Plan denied your request. The Plan says self-
administered drugs are not covered under part C. 
 
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 pay for a self-administered drug 
provided from February 11, 2022, to February 13, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paramedic intercept services provided on February 17, 2021. 
 
You asked the Plan to pay for the paramedic intercept services. You say that you have no recollection of a 
second ambulance being dispatched.  You were not the one who called for the ambulance, so you do not 
believe you should have to pay for this. The Plan denied your request. The Plan says this particular provider did 
not transport you, so these services are not covered. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for paramedic 
intercept services provided on February 17, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on April 
16, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you feel you should not 
be responsible for the full amount of this charge. The Plan denied your request. The Plan says the copayment 
that was applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for Emergency Room services.  
 
You have been asked to pay a $90 copayment for an emergency room visit. An emergency room visit falls 
within the Emergency Room 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 
an emergency room visit provided on April 16, 2022.  
 Benefits for an emergency room visit 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a pembrolizumab injection provided on 
November 2, 2021. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you had reached your out-of-pocket 
maximum for the year. 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 clearly says that you must pay a 20% 
coinsurance for each Part B drug, including chemotherapy drugs.  
 
The file shows that on the date of service, you had a total of $130 remaining to meet your maximum out-of-
pocket (MMOP) expenses for the year. Therefore, you have been asked to pay a maximum of $130, which is 
less than the 20% coinsurance for the injection ($26,740.80 allowed amount x 20% coinsurance = $5,348.16). 
The injection falls within the Medicare Part B Prescription Drugs benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for a pembrolizumab injection provided on November 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 21, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 procedure code 70450 billed for date of service April 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a bladder procedure provided on April 19, 
2022. 
 
You asked the Plan to waive the coinsurance for a bladder procedure. You say that you cannot afford this 
payment and would like it to be waived. The Plan denied your request. The Plan says the coinsurance that was 
applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 30% 
coinsurance for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. The allowed amount of this procedure is $3685.76, resulting in a coinsurance amount of 
$1105.73 ($3685.76 x 30% = $1105.73). 
 
You have been asked to pay $1105.73 coinsurance for a bladder procedure. A bladder procedure 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 coinsurance for a bladder procedure provided on April 19, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on April 
22, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that your spouse offered to 
drive you to the next location, but hospital declined. You say that you should not have to pay for the ambulance 
ride. 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 $150 
copayment for each Medicare-covered one-way ground ambulance benefit. You had one ambulance trip(s). The 
Plan charged you $150 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 provided on April 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for incontinence supplies. 
 
You asked the Plan to pay for incontinence supplies. You say that you really need these items and cannot leave 
your house if you do not have them. You said that you cannot control your urine and you cannot afford to pay 
for them yourself. The Plan denied your request. The Plan says incontinence supplies are not covered. 
 
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 pay for incontinence supplies.
Appeal type: Hospice
Decision: Favorable

 
We decided that the Plan has to pay for physician's services provided on May 25, 2021. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says that the 
member was in hospice care and the provider needs to bill Original Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided us with proof of hospice enrollment. Therefore, we 
decided that the Plan has to pay for physician's services provided on May 25, 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 coinsurance for electrocardiogram (ECG) and office visit 
on March 28, 2022. 
 
You asked the Plan to waive the coinsurance for ECG and office visit. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says the cost sharing you are being charged is 
correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 10% 
coinsurance of the approved amount for ECG. Covered services include, but are not limited to X-rays, ECG, 
EKGs, MRAs, MRIs, CT scans, PET scans, and nuclear medicine.  
 
 You must pay a 10% coinsurance of the approved amount for office visit. The health plan covers medically 
necessary doctor services and services provided by other health care providers, such as physician assistants, 
nurse practitioners, social workers, physical therapists, and psychologists. Coverage includes, but is not limited 
to consultation, diagnosis, and treatment by a specialist and second surgical opinions, and in some cases third 
opinions, when performed by a network plan provider. The provider billed in the amount of $124 and allowed 
amount is $101.47. The provider also billed in the amount of $15 and the allowed amount is $8.51. $101.47 + 
$8.51 = $109.98. 
 
You have been asked to pay $109.98 coinsurance for ECG and office visit. ECG and office visit falls within the 
Diagnostic tests and Doctor and other health provider 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 coinsurance for electrocardiogram (ECG) and office visit on March 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
January 1, 2022, to January 5, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you paid your copayment at the 
time of admission and would like verification of this bill. 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 $295 per 
day for days 1-5 and $0 per day for additional days for each inpatient admission.  
 
The file shows that you were in the hospital from January 1, 2022, to January 5, 2022. You have only been 
asked to pay $295 per day for two days of inpatient care, for a total of $590. The inpatient care 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 care provided from January 1, 2022, to January 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a biopsy provided on March 14, 2022. 
 
You asked the Plan to waive the copayment for a biopsy. You say that you should not have to pay a copayment 
that is this high. The Plan denied your request. The Plan says the copayment that was applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay a $275 copayment for a biopsy. A biopsy 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 biopsy provided on March 14, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on January 14, 2022. 
 
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on January 13, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance services 
provided on January 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital visit on March 02, 2022, 
to March 04, 2022. 
 
You asked the Plan to waive the copayment for outpatient hospital visit. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says the cost sharing you are being charged is 
correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for all other outpatient services not provided in an ambulatory surgical center. If you are having 
surgery in a hospital facility, you should check with your provider about whether you will be an inpatient or 
outpatient. Unless the provider writes an order to admit you as an inpatient to the hospital, you are an outpatient 
and pay the cost sharing amounts for outpatient surgery. Even if you stay in the hospital overnight, you might 
still be considered an outpatient.  
 You have been asked to pay a $325 copayment for outpatient hospital visit. Outpatient hospital visits fall 
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 outpatient hospital visit on 
March 02, 2022, to March 04, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an out-of-network office visit provided on 
February 2, 2022. 
 
You asked the Plan to waive the copayment for an out-of-network office visit. You say that you have multiple 
types of insurance coverage, and you shouldn't have to pay anything. 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 $40 
copayment for each out-of-network Medicare-covered primary care doctor visit.  
 
You have been asked to pay a $40 copayment for an out-of-network office visit. An out-of-network 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 an out-of-network office visit provided on February 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical-necessity rules have not been 
met because the requested services are experimental/investigational. 
 
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 pre-approve an Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Intracept procedure is experimental. More research is needed to demonstrate 
the safety and effectiveness of the procedure. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high weight capacity wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says the Medicare guidelines for authorization were not met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that there is 
inconsistent documentation that you have a personal mobility deficit that impairs participation in mobility-
related activities of daily living, such as toileting, feeding, grooming and bathing in customary locations within 
the home. A telehealth visit note dated 08/16/2022 reports a need for a power scooter but in the examination 
section of this telehealth visit notes that the neurologic exam reports "gait normal observed." There is a 
statement from the provider that you can safely operate a power mobility device although how this is 
determined from a telehealth visit is not clear. The wheelchair prescription reports bilateral sciatica but the 
provided visit notes do not document that your mobility limitation is due to a neurological condition or 
myopathy or a congenital skeletal deformity which is required for a group 3 power wheelchair. There is no 
evidence in the records of a specialty evaluation performed by a licensed/certified medical professional, such as 
a physical or occupational therapist, or practitioner who has specific training and experience in rehabilitation 
wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high weight capacity wheelchair.
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 February 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 
February 25, 2022.