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

 
We decided that the Plan does not have to waive the coinsurance for immunology on November 18, 2021. 
 
You asked the Plan to waive the coinsurance for immunology. 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 20% 
coinsurance for each Medicare-covered Part B drugs. 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. The provider billed in the amount of $150 and the allowed amount is 
$94.25. $94.25 x 20% = $18.85. The provider billed in the amount of $100 and the allowed amount is $62.83. 
$62.83 x 20% = $12.57. The provider also billed in the amount of $157 and the allowed amount is $78.21. The 
Plan paid $63.21. $78.21 - $63.21 = $15. $18.85 + $12.57 + $15 = $46.42. Therefore, results in the total cost 
sharing amount of $46.42. 
 
 
 You have been asked to pay a 20% coinsurance for immunology. This item/service 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 
immunology on November 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on May 10, 2022. 
 
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 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 each physician specialist visit for Medicare-covered services. Covered services include 
consultation, diagnosis, and treatment by a specialist.  
 
You have been asked to pay a $40 copayment for office visit. This item/service 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 office visit on May 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a wrist-hand-finger orthosis provided on 
April 22, 2022. 
 
You asked the Plan to waive the coinsurance for a wrist-hand-finger orthosis. You say that this is classed as a 
prosthetic not DME. The cost should be less. 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. The allowed amount of this drug or 
item is $175.76, resulting in a coinsurance amount of $35.15 ($175.76 x 20% = $35.15). There is still a 20% 
coinsurance for DME. 
 
You have been asked to pay a $35.15 coinsurance for a wrist-hand-finger orthosis. 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 a wrist-hand-finger orthosis provided on April 
22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan 
provided on July 18, 2022. 
 
You asked the Plan to waive the copayment for the computed tomography (CT) scan. You say that you would 
like to dispute the copayment that was applied 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 $200 
copayment for complex radiology CT scans per provider, per date of service. 
 
You have been asked to pay a $200 copayment for the computed tomography (CT) scan. This item/service falls 
within the complex radiology CT scans per provider, per date of service 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 computed tomography (CT) scan provided on July 18, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance services provided to the enrollee on May 30, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the services required to treat the beneficiary were available at the transferring facility. 
 The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 pay for the services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found that the 
documentation does not support that the patient's condition was such that the time needed to transport a patient 
by ground, or the instability of transportation by ground, posed a threat to the patient's survival or seriously 
endangered the patient's health. The patient was transferred by air from a medical center in the United States 
Virgin Islands to the mainland United States. The transferring hospital has a vascular surgery department, and 
it is not well documented why vascular services could not be provided without transfer. The documentation 
does not support that the transferring hospital did not have adequate facilities to provide the medical services 
needed by the patient. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for air ambulance services provided to the enrollee on May 30, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to lower the copayments for wound procedures provided from May 6, 
2022, to June 13, 2022. 
 
You asked the Plan to lower the copayments for wound procedures. You say that this has caused a financial 
hardship and you are no longer able to treat these wounds. Please lower these copayments. 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 $275 
copayment for outpatient diagnostic tests and therapeutic services and supplies. Some of your procedures were 
less than the $275 copayment, some were the full amount. This created the total of $1,150.05 ($159.10 + 
$990.95 = $1,150.05). 
 
You have been asked to pay a $1,150.05 total copayment for wound procedures. 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 lower the copayments for wound procedures provided from May 6, 2022, to June 13, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for angiography, extremity, bilateral, radiological supervision 
and interpretation provided to the enrollee on July 14, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this procedure is considered inclusive to CPT 37224. 
 
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 75716 is "Angiography, extremity, bilateral, radiological 
supervision and interpretation." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in its current state, the 
documentation provided does not sufficiently support coverage of code 75716. For diagnostic angiography to 
separately billable from 37224, there has to have been no recent previous angiogram or computed tomography 
angiography (CTA). However, the documentation clearly indicates that the patient was to obtain a CTA and 
that subsequent decisions will be made thereafter. If this CTA was not performed, recommend resubmitting 
with documentation that no diagnostic CT angiogram or other angiography was recently previously performed. 
 
We looked at this coder's review, the file, and Medicare rules. 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 angiography, extremity, bilateral, radiological supervision and interpretation provided to the 
enrollee on July 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an echocardiography (93306) provided on 
July 14, 2022 
 
You asked the Plan to waive the copayment for the echocardiography. You say that the services should be 
covered as you disagree with the denial. 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 $50 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $50 copayment for the echocardiography. 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 echocardiography (93306) provided on July 14, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the orthopedic surgeon office visit provided 
on January 27, 2022. 
 
You asked the Plan to waive the copayment for the orthopedic surgeon office visit. You say that you needed to 
see the provider for a new brace 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 $45 
copayment for each covered visit or consultation in an outpatient location with a specialist. 
 
You have been asked to pay a $45 copayment for the orthopedic surgeon office visit. This item/service falls 
within the each covered visit or consultation in an outpatient location with a 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.  Therefore, we decided that 
the Plan does not have to waive the copayment for the orthopedic surgeon office visit provided on January 27, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency transportation provided on January 5, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the non-emergency transportation. You say that you would like a retro 
authorization because care was not available at the original destination. The Plan denied your request. The Plan 
says the rendering provider is an OON provider and there was no approved 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 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 the non-emergency transportation provided on 
January 5, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
April 10, 2022, to April 15, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you would like the 
copayment waived because you were sent to the inpatient hospital from your local hospital. 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 $350 
copayment per day for days 1-5 and $0 after day 5 for each time you are admitted to an acute care hospital. The 
day before you are discharged is your last inpatient day. From April 10, 2022, to April 15, 2022, there was a 
total of 5 days at the inpatient hospital stay. Since the day prior to discharge is the last day there was a total of 4 
days at the inpatient hospital. The total copayment amount for 4 days would be $1,400 ($350 copayment per 
day x 4 days). The Plan charged $700 for the total copayment amount which is less than the $1,400. 
 
  You have been asked to pay a $700 copayment for the inpatient hospital stay. This item/service falls within the 
inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient 
hospital stay provided from April 10, 2022, to April 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an orthopedic visit provided on July 19, 
2022. 
 
You asked the Plan to waive the copayment for an orthopedic visit. You say that you went there for injections 
but they did not have the medication. You did talk to the provider while you were there. 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 Physician/Practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for an orthopedic visit. This item/service 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 orthopedic visit provided on July 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda to be used in combination with carboplatin 
and pemetrexed. 
 
You asked the Plan to pre-approve Keytruda to be used in combination with carboplatin and pemetrexed. You 
say that the requested Keytruda to be used in combination with carboplatin and pemetrexed is medically 
necessary. The Plan denied your request. The Plan says the requested Keytruda to be used in combination with 
carboplatin and pemetrexed is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda to be used in combination 
with carboplatin and pemetrexed. Our reviewer says that the requested Keytruda to be used in combination 
with carboplatin and pemetrexed is not medically necessary. Our physician reviewer found the record indicates 
that the enrollee has a diagnosis of metastatic Non-Small Cell Lung Cancer. The record indicates that the 
results of testing for the presence of oncogene driver mutations are pending and therefore not unavailable. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. 
The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested 
drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted 
for review. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda to be used in combination with carboplatin and pemetrexed have not 
been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda to be used in 
combination with carboplatin and pemetrexed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided on June 
19, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were not aware that 
you would be responsible for the charges and that you only expected to be responsible for half. The Plan denied 
your request. The Plan says this cost sharing was charged correctly. The Plan says you are responsible for 
understanding your benefits 
 
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 $300 
copayment per day for the first 5 days of inpatient hospital care.  
 
You have been asked to pay a $900 copayment for three days of an inpatient hospital stay ($300 copayment  3 
days = $900). This item/service falls within the inpatient hospital care benefit category.  
 
 This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an inpatient hospital stay provided on June 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
May 27, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service May 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received on October 2, 2021. 
 
You asked the Plan to pay for the drugs. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
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 self-administered drugs received 
on October 2, 2021.