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

 
We decided that the Plan does not have to waive or reduce the copayment for a back injection provided on 
January 24, 2022. 
 
You asked the Plan to waive or reduce the copayment for the injection. You say that the cost for this procedure 
is too high. 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 $250 
copayment for outpatient procedures and services.  
 
You have been asked to pay a $250 copayment for the injection. The injection 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 or reduce the copayment for a back injection provided on January 
24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex. 
 
You asked the Plan to pre-approve Vertiflex. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested services are not medically necessary. 
 
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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has degenerative disc disease of the lumbar spine, right lumbar radicular pain and 
lumbar foraminal 
stenosis with neurogenic claudication. Vertiflex is experimental. More research is needed. Therefore, the 
enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vertiflex.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 21, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 an office visit provided on March 21, 2022, by an 
out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided February 23, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that a nurse demanded that you call 911, 
therefore you feel the ambulance response should be covered. The Plan denied your request. The Plan says this 
service is not covered because there was no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.   
The ambulance company did not provide transport services on February 23, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided February 23, 2022.
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 7, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like the Plan to 
reconsider their denial of payment. 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 7, 2022.
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 April 3, 
2022. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that you are on a fixed income and 
cannot afford the copayment. 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 each specialist visit, including telehealth services.  
 
You have been asked to pay a $45 copayment for the specialist visit. The specialist visit falls within the 
Physician/Practitioner Services, Including Doctor's 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 April 3, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance on April 07, 2022. 
 
You asked the Plan to waive the copayment for ambulance. You say that the service you received from the fire 
department was unacceptable. You did not want to be transported for your broken arm, but EMS insisted that 
you go anyway. You stated that the EMS were unprofessional, and they did not know what they were doing. 
You feel that you should be charged for the services. 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 $240 
copayment per date of service regardless of the number of trips for ground ambulance. Covered ambulance 
services include fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that 
can provide care only if they are furnished to a member whose medical condition is such that other means of 
transportation could endanger the persons health of if authorized by the plan.  
 
 You have been asked to pay a $240 copayment for ambulance. Ambulance 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. 
Therefore, we decided that the Plan does not have to waive the copayment for ambulance on April 07, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx (F1CDx) testing provided on February 7, 
2022. 
 
You asked the Plan to pay for the F1CDx testing. You say that this is an FDA-approved test that is covered by 
Medicare. The Plan denied your request. The Plan says that there is a Local Coverage Determination (LCD) 
that indicates that any panel that tests for the FANCC gene is noncovered. Since this panel includes the 
FANCC gene, the denial is correct. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, such as the F1CDx panel, when provided for an FDA-approved indication. 
 
We looked at the file and Medicare rules. This testing was provided to an enrollee with metastatic cancer. The 
FDA approval notice indicates that this panel is approved for metastatic cancer. No other valid denial rationale 
was presented by the Plan. Based on this information, we decided that Medicare rules for coverage of the 
F1CDx testing have been met. Therefore, we decided that the Plan has to pay for the FoundationOne CDx 
(F1CDx) testing provided on February 7, 2022.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87500, 87640, 87641, 87653, 
87798, and 87801 billed for date of service August 9, 2021. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87500, 87640, 87641, 87653, 87798, and 87801. 
You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The 
Plan says payment for code 87150 is bundled into payment for code 87500. Procedure code 87500 is not 
supported in the records provided. Payment for code 87481 is bundled into payment for codes 87150 and 
87801. Payment for code 87640 is bundled into payment for codes 87150, 87641, and 87801. Payment for code 
87641 is bundled into payment for codes 87180 and 87801. Payment for code 87653 is bundled into payment 
for codes 87150 and 87801. Payment for code 87798 is bundled into payment for codes 87150 and 87801. 
Payment for code 87801 is not supported in the records provided. 
 
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 87150 
is a column II code to column I code 87500. Code 87500 is not supported in the records provided. Code 87481 
is a column II code to column I codes 87150 and 87801. Code 87640 is a column I code to column II codes 
87150, 87641, and 87801. Code 87641 is a column I code to column II codes 87180 and 87801. Code 87653 is 
a column I code to column II codes 87150 and 87801. Code 87798 is a column I code to column II codes 87150 
and 87801. Payment for code 87801 is not supported in the records provided. 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 codes 87150, 87481, 
87500, 87640, 87641, 87653, 87798, and 87801 billed for date of service August 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided to the enrollee 
on February 24, 2021. 
 
You asked the Plan to waive the copayment for the lab services. You say that the enrollee was never charged 
for labs before. The Plan denied your request. The Plan says the enrollee has 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $10 copayment per day for lab services.  
 
The enrollee has been asked to pay a $10 copayment for the lab services. The lab services fall within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that the 
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for laboratory services provided to the enrollee on February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for office visits provided on April 5, 2022, 
and April 16, 2022. 
 
You asked the Plan to waive the coinsurance for office visits. You say that you did not agree to be seen by the 
doctor or have any care. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance of the total cost for each Medicare covered primary care doctor visit.  
 
You have been asked to pay $33.66 which is 20% of the total cost for office visits. Office visits fall within the 
Physician/Practitioner Services, Including Doctors Office Visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for office visits provided on April 5, 2022, and April 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on December 21, 2021. 
 
You asked the Plan to waive the copayment for 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 $20 
copayment per visit to a specialist. Covered services include consultation, diagnosis, and treatment by a 
specialist. 
 
You have been asked to pay a $20 copayment for office visit. Office visits fall within the Physician/Practitioner 
services, including doctor's 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 office visit on December 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out-of-network (OON) chiropractic 
services provided from February 7, 2022, to March 21, 2022. 
 
You asked the Plan to waive the coinsurance for the OON chiropractic services. You say that you should be 
reimbursed for the services. 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 50% 
coinsurance for chiropractic services with an out-of-network provider.  
 
The file shows that the Plan verified the provider is not a network provider. Therefore, you have been asked to 
pay $16 for each of the four chiropractic visits, which is 50% of the allowed amount ($32 allowed amount x 
50% coinsurance = $16). The total for all visits is $64. The OON chiropractic services fall within the 
Chiropractic 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 out-of-
network (OON) chiropractic services provided from February 7, 2022, to March 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for a procedure provided on February 17, 2022. 
 
You asked the Plan to waive the cost for a procedure. You say that the provider put the injections in the wrong 
spot, therefore you feel you should not need to pay this cost share. The Plan denied your request. The Plan says 
the cost 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 $125 
copayment after the deductible is met for outpatient hospital observation, and a $750 deductible for applicable 
services.  
 
You have been asked to pay $496.16 of your deductible for a procedure. A procedure falls within the 
Outpatient Hospital Observation 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 for a 
procedure provided on February 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Part B drug and office visit on April 11, 
2022. 
 
You asked the Plan to waive the cost share for Part B drug and office visit. You say that you feel it should be 
covered in full by the insurance because it is a medical procedure that you are getting. It is ongoing and we are 
talking about your health here, and it is not an unnecessary procedure it is needed to insure your ongoing good 
health. 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 20% 
coinsurance for Medicare Part B drug obtained in a providers office or outpatient setting. These drugs are 
covered under Part B of Original Medicare. Members of our plan receive coverage for these drugs through our 
plan. 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 $45 for each Medicare-covered visit with a specialist. Covered services include consultation, diagnosis, 
and treatment by a specialist. The provider billed in the amount of $8.00 and the allowed amount is $1.12. 
$1.12 x 20% = $0.22. $45 + $0.22 = $45.22. Therefore, results in the total cost sharing amount of $45.22 
 
You have been asked to pay a 20% coinsurance for Part B drug and $45 copayment for office visit. Part B drug 
and office visits fall within the Medicare Part B prescription drugs and Physician/Practitioner services, 
including doctor's 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 Part B drug 
and office visit on April 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an outpatient hospital visit provided on 
March 4, 2022. 
 
You asked the Plan to waive the deductible for an outpatient hospital visit. You say that you didn't know you 
had a deductible and feel you should not have to pay this amount. The Plan denied your request. The Plan says 
the deductible 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 $750 
deductible for outpatient hospital services and applicable services.  
 
You have been asked to pay a $105.50 deductible for an outpatient hospital visit. An outpatient hospital visit 
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 waive the deductible 
for an outpatient hospital visit provided on March 4, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on March 29, 2022. 
 
You asked the Plan to waive the coinsurance for an injection. You say that this should be covered in full. The 
Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for Part B drugs that are administered by a provider.  
 
You have been asked to pay $251.64 which is 20% of the allowed amount for an injection.  The allowed 
amount is $1,258.22 (20% x $1,258.22= $251.64). Injections fall within the Medicare Part B Prescription 
Drugs benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the coinsurance for an injection provided on March 
29, 2022.