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

 
We decided that the Plan does not have to pre-approve knee pain treatment to be rendered by the out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are in-network providers available to render the 
requested service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the service at issue in this appeal. We found no exception that would require the 
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve knee pain 
treatment to be rendered by the out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the TDAP vaccine and immunization administration (90471) 
provided on November 4, 2021 
 
You asked the Plan to pay for the TDAP vaccine and immunization administration (90471). You say that you 
work with metals, cutting instruments, tools and shop materials increasing the possibility of accidents/infection 
from cuts. You say that it was decided that getting the vaccination was justified. The Plan denied your request. 
The Plan says a tetanus vaccine is not covered when received as a preventive measure. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the TDAP vaccine 
and immunization administration (90471). The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the TDAP vaccine 
and immunization administration (90471). Therefore, we decided that the Plan does not have to pay for the 
TDAP vaccine and immunization administration (90471) provided on November 4, 2021  
  Benefits for the TDAP vaccine and immunization administration (90471) 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a Computerized Tomography (CT) scan on 
October 29, 2021. 
 
You asked the Plan to waive the copayment for a Computerized Tomography (CT) scan. You say that you do 
not believe that you should have a cost share for this CT scan. The Plan denied your request. The Plan says the 
copayment 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 a Computerized Tomography (CT) scan.  
 
You have been asked to pay a $325 copayment for a Computerized Tomography (CT) scan. A Computerized 
Tomography (CT) scan 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 Computerized Tomography 
(CT) scan on October 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from 
June 21, 2021, to June 29, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. 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 $325 per day for days 1-5 and $0 per day for days 6 to discharge for each inpatient admission.  
 
The file shows that the enrollee was in the hospital from June 21, 2021, to June 29, 2021. The enrollee has been 
asked to pay $325 per day for the first 5 days of inpatient hospital services. The total for the stay is $1,625, however the enrollee had met their maximum out-of-pocket (MOOP) expenses for the year. Therefore, the 
enrollee is only responsible for the remaining $1,480. The inpatient hospital services fall within the Inpatient 
Hospital Care 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 inpatient 
hospital services provided from June 21, 2021, to June 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital surgery provided on 
October 5, 2021 to November 2, 2021. 
 
You asked the Plan to waive the copayment for outpatient hospital surgery. You say that the copayment should 
be waived  because you were not at a hospital. The Plan denied your request. The Plan says the copayment 
amount 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 $250 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital.  
 
 You have been asked to pay a $61.95 copayment for each date of service for outpatient hospital surgery, 
totaling $309.75 for five dates of service ($61.95 x 5), which is less than the Plans EOC documented $250 
copayment for outpatient hospital surgery. Outpatient hospital surgery falls within the Outpatient Surgery and 
Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for outpatient hospital surgery provided on October 
5, 2021 to November 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an incision and drainage of abscess (10061) provided on July 
21, 2021. 
 You asked the Plan to pay for an incision and drainage of abscess. You say that the service at issue was a 
requirement for the enrollee's condition. The Plan denied your request. The Plan says rules for payment have 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 10061 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of an 
incision and drainage of abscess have not been met. Therefore, we decided that the Plan does not have to pay 
for an incision and drainage of abscess (10061) provided on July 21, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing 
services, the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively 
provide treatment. The documentation does not support that it is medically reasonable and necessary to provide 
skilled therapy services on a daily basis, on an inpatient basis, in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 25, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says when specimen 
validity testing is conducted as part of drug testing, it cannot be billed separately. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing shall not separately bill the validity testing.  
 
 
 
 
 
 We looked at the file and Medicare rules. In this case, the requested validity testing is not separately payable. 
Based on this information, we decided that Medicare rules for coverage of the services have not been met. 
Therefore, we decided that the Plan does not have to pay for the lab services provided on August 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on October 
25, 2021. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that you feel the copayment 
should be waived since it was related to COVID-19. 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 $55 
copayment for each urgent care provider visit.  
 
The file shows that the Plans COVID-19 cost share waiver ended on September 30, 2021. Therefore, you have 
been asked to pay a $55 copayment for the urgent care visit. The urgent care visit falls within the Urgently 
Needed 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 urgent care visit 
provided on October 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services provided 
on November 26, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the services should 
be covered. 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 ambulance trip. 
 Service Allowed Amount 20% Coinsurance 
Ground Mileage (A0425) $94.44 $18.89 
Basic Life Support, Emergency (A0429) $351.56 $70.31 
Total:  $89.20 
 
You have been asked to pay $89.20, which is 20% of the allowed amount for the ambulance transportation. The 
ambulance transportation falls within the Ambulance Emergency 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 transportation services provided on November 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Ankle surgery on August 24, 2021. 
 
You asked the Plan to waive the copayment for Ankle surgery. You say that you shouldn't have to pay the 
copayment due to the doctor's error. The Plan denied your request. The Plan says the copayment 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 $350 
copayment for Ankle surgery.  
 
You have been asked to pay a $350 copayment for Ankle surgery. Ankle 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 Ankle surgery on August 24, 2021.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the colonoscopy with a biopsy rendered on October 
12, 2021. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that you believe it should be covered 
like your previous colonoscopies The Plan denied your request. The Plan says that the copayment applied is 
correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $0 copayment for any surgical procedures (i.e., polyp 
removal) during a colorectal screening. This colonoscopy was provided as a screening service and a polyp 
removal was included in the procedure; therefore, the $0 copayment applies to this procedure. 
 
The Plan says you must pay a $330 copayment for the colonoscopy with a biopsy. Based on the Plan contract, 
however, you cannot be asked to pay more than a $0 copayment for the colonoscopy with a biopsy. Therefore, 
we decided that the Plan has to waive the copayment for the colonoscopy with a biopsy rendered on October 
12, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 2, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
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 lab 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 lab services provided on September 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on October 18, 2021. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you feel that the charges should be 
covered because you had abnormal findings on a lung cancer screening. The Plan denied your request. The 
Plan says the claims were processed correctly and you are being charged the correct 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 $110 
copayment for radiological diagnostic services.  
 
 
 You have been asked to pay the allowed amount of $86.10, which is less than the $110 copayment for a CT 
scan. A CT scan 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 computed tomography (CT) scan provided on 
October 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a bone marrow biopsy performed on 
October 22, 2021. 
 
You asked the Plan to waive the copayment for the bone marrow biopsy. You say that you were not aware of 
the copayment for the procedure. 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 each outpatient hospital facility visit.  
 
 
 You have been asked to pay a $250 copayment for the bone marrow biopsy. The bone marrow 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 bone marrow 
biopsy performed on October 22, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on March 11, 2021. 
 
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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on March 11, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services provided on July 5, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the services were 
billed with the incorrect place of service. 
 
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 argues that the services in question were billed with the incorrect place 
of service. However, the Plan has not provided the claim form or any documentation showing the billed place 
of service. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided 
that the Plan has to pay for the services provided on July 5, 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 pay for the telephone evaluation and management service (99443) 
rendered by the out-of-network (OON) provider on July 15, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the telephone evaluation and management service (99443) rendered by the out-of-
network (OON) provider on July 15, 2021.