Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for oxygen equipment provided from 
February 11, 2022, to June 10, 2022. 
 
You asked the Plan to waive the coinsurance for oxygen equipment. You say that you cannot afford these 
payments each month. 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 durable medical equipment (DME) and related supplies ($94.14 + $107.55 + $539.00 + 
$104.08 + $596.75 = $1441.52).  
 
You have been asked to pay a $1441.52 coinsurance for oxygen equipment. This item/service falls within the 
durable medical equipment (DME) and related 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 coinsurance for oxygen equipment provided from February 11, 2022, to June 10, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient services on March 30, 2022, to 
April 13, 2022. 
 
You asked the Plan to waive the copayment for outpatient services. 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 $370 
copayment per day for other outpatient procedures and services, including, but not limited to, diagnostic and 
therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical 
center. There were 2 dates of service. 2 x $370 = $740. Therefore, resutls in the total cost sharing amount of 
$740.  
 
 You have been asked to pay a $370 copayment for each outpatient services. 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 outpatient services on March 30, 
2022, to April 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 3 Sensor. 
 
You asked the Plan to pre-approve a FreeStyle Libre 3 Sensor. You say that the item is necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CGM devices that do not meet the definition of a 
therapeutic CGM as defined in CMS Ruling 1682R will be denied as non-covered (no benefit).   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a FreeStyle Libre 3 Sensor have not been met. Specifically, the requested CGM device does not 
meet the definition of a therapeutic CGM. Non-Therapeutic CGMs are not covered by Medicare or the Plan. 
Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre 3 Sensor.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on June 13, 2022. 
 
You asked the Plan to waive the copayment for emergency care. You say that you should not be responsible to 
pay 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for emergency care. This item/service falls within the emergency 
care benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.  
Therefore, we decided that the Plan does not have to waive the copayment for emergency care provided on 
June 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a myocardial perfusion imaging provided 
on June 01, 2022. 
 
You asked the Plan to waive the copayment for a myocardial perfusion imaging. You say that you were not 
aware of how much this test would cost. 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 $175 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $175 copayment for a myocardial perfusion imaging. 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 myocardial perfusion imaging provided on June 01, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visits provided on 
October 07, 2021, to October 21, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visits. You say that you are appealing these 
charges. 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 $100 
copayment for physician/practitioner services, including doctors office visits (specialist). 
 
You have been asked to pay a $100 copayment for the specialist office visits. This item/service falls within the 
physician/practitioner services, including doctors office visits (specialist) 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. Per the EOC, there is a $50 copayment 
for specialist visits. The file shows two visits from October 7, 2021, to October 21, 2021, for a total of $100. 
Therefore, we decided that the Plan does not have to waive the copayment for the specialist office visits 
provided on October 07, 2021, to October 21, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on January 3, 2022, to January 24, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for physical therapy. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
  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 physical therapy provided on January 3, 2022, to 
January 24, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retinal imaging and the office visit provided on July 20, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the retinal imaging and the office visit. You say that you were unaware that you 
needed a referral for your eye exam. The Plan denied your request. The Plan says the provider is out-of-
network. 
 
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 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 the retinal imaging and the office visit provided on 
July 20, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pairing or cutting of benign hyperkeratotic lesion (corn or 
callus) provided on June 20, 2022. 
 
You asked the Plan to pay for the routine foot care service. You say that you have a lesion. You say that you 
have hammer toes. You also say that the doctor scrapes the bottom of your foot to help with your pain. The 
Plan denied your request. The Plan says routine foot care services are excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the 
routine foot care service have not been met. Therefore, we decided that the Plan does not have to pay for 
pairing or cutting of benign hyperkeratotic lesion (corn or callus) provided on June 20, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services on April 16, 
2022. 
 
You asked the Plan to waive the copayment for emergency room services. 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 $90 
copayment for each emergency room visit. Emergency care refers to services that are furnished by a provider 
qualified to furnish emergency services, and needed to evaluate or stabilize an emergency medical condition. 
 
You have been asked to pay a $90 copayment for emergency room services. This item/service falls within the 
Emergency Care benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency room 
services on April 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you were independent before being hospitalized and 
you would like to return to being independent. You think you would receive better care in the IRF then in a 
SNF setting. The Plan denied your request. The Plan says criteria for admission to the Acute Inpatient 
Rehabilitation setting have not been met. Your ongoing skilled therapy and nursing needs can be provided at a 
lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found your medical problems are stable and there are no complex nursing or rehabilitation 
needs. There is no documented need for intensive rehabilitation services and medically necessary care can be 
provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for discharge day services provided on May 29, 2021. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the code is not 
supported. 
 
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 99239 is hospital discharge day management; more than 
30 minutes. We find that CPT code 99239 is not supported in the medical record. Specifically, the records do 
not document the total time spent. Based on this information, we decided that Medicare rules for coverage of 
the billed services have not been met. Therefore, we decided that the Plan does not have to pay for discharge 
day services provided on May 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a positron emission tomography (PET) 
scan provided on April 21, 2022. 
 
You asked the Plan to waive the coinsurance for a PET scan. You say that you already paid a copayment for 
this test, and you feel you should not have to pay a coinsurance. 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 outpatient diagnostic tests and therapeutic services and supplies. The allowed amount of this 
item or service was $5472, resulting in a coinsurance of $1094.40 ($5472 x 20% = $1094.40). 
 
You have been asked to pay a $1094.40 coinsurance for a PET scan. 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 coinsurance for a positron emission tomography (PET) scan 
provided on April 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care visit provided on December 
18, 2021. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that you only went for a COVID-
19 test and should not be 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 $40 
copayment for urgently needed services with any provider other than your PCP. 
 
You have been asked to pay a $40 copayment for the urgent care visit. This item/service falls within the 
urgently needed services with any provider other than your PCP 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 urgent care visit provided on December 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle, group 1 standard, patient 
weight capacity up to and including 300 pounds (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that you have been wearing a boot for 12 weeks 
and will be having surgery on your foot. You had a wheelchair before, but your wife was unable to push you 
due to her physical limitations. The Plan denied your request. The Plan says there is no mobility assessment to 
evaluate any of the above criteria needed to determine whether a power operated scooter is medically 
necessary. 
 
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.  
 
 
 
 The file does not show that you have a mobility deficit that impairs your participation in MRADLs. The 
records show that you have not had a mobility assessment. A medical assessment is needed to determine 
medical necessity and whether the purpose of the request is for inside or outside of the home. This means that 
Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power operated vehicle, group 1 standard, patient weight capacity up to and including 300 
pounds (K0800).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) provided on 
April 11, 2022. 
 
You asked the Plan to waive the copayment for an EKG. You say that this was part of a preoperative 
appointment and shouldn't have any additional charges. 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 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $13.24, which is less than the original copayment of $20 for an EKG. 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 an electrocardiogram (EKG) provided on April 11, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on May 10, 
2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you were unable to know if 
the EMS was in-network. 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 $305 
copayment for ambulance services. 
 
You have been asked to pay a $305 copayment for ambulance services. This item/service falls within the 
ambulance services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Please note the copayment applies to both in-network and out-of-network ambulance services. 
Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided on 
May 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service April 10, 
2022. 
 
You asked the Plan to pay for procedure code 93042. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 93042 is bundled into payment for code 93010. 
 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 93042 
is a column II code to column I code 93010. 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 93042 billed for date of service April 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the mammogram and breast ultrasound 
provided on March 30, 2022. 
 
You asked the Plan to waive the deductible for the mammogram and breast ultrasound. You say that you were 
informed that all services would 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 $395 
deductible for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $395 deductible for the mammogram and breast 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 deductible for the mammogram and breast ultrasound provided on March 30, 2022.