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

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on April 29, 2021. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you believe the doctor billed this 
incorrectly. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay 20% coinsurance for Medicare covered Part B drugs.  
 
The enrollee has been asked to pay $1,959.84 which is 20% of the allowed amount for an injection. The 
allowed amount is $9,799.20(20% x $9,799.20= $1,959.84). Injections fall within the Medicare Part B 
Prescription Drugs 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 coinsurance for an 
injection provided on April 29, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility (SNF) stay 
provided from March 1, 2022, to March 10, 2022. 
 
You asked the Plan to waive the copayment for the SNF stay. You say that you were forced to stay an extra 10 
days because you tested positive for COVID-19. The Plan denied your request. The Plan says the copayment 
was applied 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 for days 
1-20: a $0 copay per day (per benefit period) and days 21-100: a $172 copay per day (per benefit period).  
 
 
  You have been asked to pay $1,204 ($172 copay x 7 days) for the SNF stay. The SNF stay falls within the 
Skilled Nursing Facility (SNF) 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 a 
skilled nursing facility (SNF) stay provided from March 1, 2022, to March 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplicate x-ray provided to the enrollee on January 31, 
2022. 
 
You asked the Plan to pay for the services. You say that the claim denied as duplicate in error. The Plan denied 
your request. The Plan says the records submitted do not indicate that two separate services were 
performed/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.  
 
We find that CPT code 74230 is not supported in the medical record. Specifically, the records show that only 
one x-ray was rendered in this case. 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 a duplicate x-ray 
provided to the enrollee on January 31, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial nursing facility care (99304) provided on April 20, 
2022. 
 
You asked the Plan to pay for the nursing facility care. You say that the enrollee was not enrolled in hospice for 
the date of service in this case. The Plan denied your request. The Plan says the enrollees claim would be 
covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the providers 
responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice.  
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 the initial nursing facility care (99304) provided on April 20, 
2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection, anesthetic agent and/or steroid; femoral nerve 
(64447) provided on July 18, 2021. 
 
You asked the Plan to pay for the injection. You say that the service should be covered. The Plan denied your 
request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible for 
coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is 
revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering 
services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 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 date of service at issue in this appeal. Though the 
enrollee revoked their hospice election on the date of service in this case, Original Medicare as it is responsible 
for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice 
is revoked. Therefore, we decided that the Plan does not have to pay for the injection, anesthetic agent and/or 
steroid; femoral nerve (64447) provided on July 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4649 billed for date of service January 7, 
2022. 
 
You asked the Plan to pay for procedure code A4649. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code A4649 is considered bundled and not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 
 We find that procedure code A4649 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A4649 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4649 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4649 billed for date of service January 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the eye exam (92012) provided on 
October 26, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to waive the coinsurance for the eye exam. You say that you paid $130 out of pocket for 
this exam. The Plan denied your request. The Plan says the coinsurance amount you are being charged is 
correct. The Plan also says that the Plan payment amount was $26, and you were reimbursed the maximum 
reimbursement of $45 instead. 
 
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 an 80% 
coinsurance for Out-of-network routine vision care.  
 
 
  You have been asked to pay an 80% coinsurance for the eye exam. The eye exam falls within the Out-of-
network routine vision care benefit category. The record shows the total cost for this exam was $130. The total 
cost of $130 times the coinsurance amount of 80% leaves you responsible for an amount of $104. The record 
shows that the Plan paid $45 for this service, which is more than the 20% coinsurance they are responsible for. 
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 the eye exam (92012) provided on October 26, 2021, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for telehealth visit provided on February 28, 
2022. 
 
You asked the Plan to waive the copayment for telehealth visit. You say that since this was a follow up it 
should be covered. The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $40 
copayment for each covered visit or consultation in an outpatient location with a specialist.  
 
You have been asked to pay $40 copayment for telehealth visit. Telehealth 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 copayment for telehealth visit provided on February 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 7, 2021. 
 
You asked the Plan to pay for the testing services. You say that the services were appropriate based on the 
enrollee's past medical history. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria. 
 
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 pay for the testing services. Our physician reviewer 
found that the enrollee has malignant neoplasm of connective and soft tissue of head, face and neck, Basal cell 
carcinoma of skin of other parts of face, and long-term (current) use of antithrombotics/antiplatelets. The 
limited clinical documentation in the case file does not support that the testing in this case was medically 
reasonable and necessary or would impact the management and outcome of the enrollee. 
 
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 testing services have not been met. Therefore, we decided that the Plan does 
not have to pay for the genetic testing provided on October 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an office visit and x-ray provided on April 
12, 2022. 
 
You asked the Plan to waive the cost share for an office visit and x-ray. You say that you weren't aware there 
would be any charges. The Plan denied your request. The Plan says the cost share 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 there is $233 deductible which office visits and x-rays and a 20% coinsurance 
that applies to basic radiological services.  
 
The item or service you asked the Plan to waive the cost share for falls within the benefit category 
Physician/Practitioner Services, Including Doctors Office Visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is $233 deductible which applies to Physician/Practitioner Services, 
Including Doctors Office Visits. This cost sharing is a contractual obligation that had not been met at the time 
an office visit and x-ray was received on April 12, 2022. Therefore, $216.44 has been applied to meet the 
deductible. You have also been asked to pay 20% coinsurance for x-ray. 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 the Plan does not have to waive the cost for office 
visit and x-ray provided on April 12, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the screening mammography and breast tomosynthesis provided on 
February 28, 2022. 
 
You asked the Plan to pay for the screening mammography and breast tomosynthesis. You say that these 
services were billed correctly and should be paid. The Plan denied your request. The Plan says that this claim 
denied correctly. 
 
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. Specifically, the Plan's sole rationale for denial is that the claim "amount 
exceeds your contractual agreement."  However, this doesn't make sense, considering that you are not a 
contract provider with the Plan. The Plan has provided no other evidence to support its denial.  There is no 
evidence that you have been paid anything for this claim.  There is no evidence that the Plan has paid another 
provider for the same services.  The Plan has failed to provide any proof that the number of these services 
exceeds what is coverable.  The burden is on the Plan to support its denial and it has failed to do so in this case 
by failing to provide any documentation to support its denial rationale. Therefore, we decided that the Plan has 
to pay for the screening mammography and breast tomosynthesis provided on February 28, 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, emergency 
transport (A0429) and ground mileage (A0425) provided on November 26, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee was not in hospice on the date 
of service in this case. The Plan denied your request. The Plan says the enrollees claim would be covered 
under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until 
the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to 
verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on November 19, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the ambulance 
service, basic life support, emergency transport (A0429) and ground mileage (A0425) provided on November 
26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee surgery. 
 
You asked the Plan to pre-approve knee surgery. 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 knee surgery. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee was being treated for pain in the left knee. The enrollee presented with left knee 
pain that is located medially. Symptoms are worse with stairs or twisting and are better with rest. The exam 
reveals she walks with a slight left-sided limp. There is medial joint tenderness. Twisting gives medial joint 
line tenderness. There is trace knee effusion. The range of motion is full extension with flexion to 130. 
Conservative treatment included Tylenol, physical therapy, and cortisone injection. detailed documentation is 
not evident regarding diagnostic imaging supporting a meniscal tear. The march 23, 2021 left knee magnetic 
resonance imaging states possible small non-displaced medial meniscal tear, along with "very mild arthritis." 
This would not be an indication for surgical repair in itself. An exception would not be indicated (as there is no indication of mechanical symptoms in the left knee on the April 20, 2022 exam). There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. 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 knee surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve knee surgery.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for outpatient surgery and self-administered drugs 
provided from January 10, 2022, through January 20, 2022.  You asked the Plan to waive the cost for outpatient surgery and self-administered drugs. You say that you are 
appealing the denial for the self-administered drugs you received while in the hospital. You say that you feel 
you should not owe it. The Plan denied your request. The Plan says the claim processed 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). The rules say that Medicare Part B generally does not pay for self-
administered drugs.  
 
You have been asked to pay a $325 copayment for the outpatient surgery. The outpatient surgery falls within 
the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers benefit category. You are also responsible for the cost of the self-administered drugs and can submit a 
request for coverage to Part D. 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 outpatient surgery and self-
administered drugs provided from January 10, 2022, through January 20, 2022.  
 
Benefits for the self-administered drugs 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan has properly assessed the maximum out-of-pocket amount for medical services 
provided from November 2, 2021, to November 30, 2021. 
 
You asked the Plan to properly assess and change the maximum out-of-pocket amount for medical services. 
You say that you hit your maximum out-of-pocket amount prior to November 2, 2021. The Plan denied your 
request. The Plan says the enrollee did not hit their yearly maximum out-of-pocket amount prior to the dates of 
service. 
 
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 $7,550 
maximum out-of-pocket amount. The amounts you pay for copayments and coinsurance for in-network 
covered services count toward this maximum out-of-pocket amount. Prior to November 2, 2021, the total 
amount paid towards the maximum out-of-pocket amount was $2,142.24. Leaving a balance of $5,407.76 
($7,550 maximum out-of-pocket - $2,142.24 paid toward maximum out-of-pocket) to pay towards the 
maximum out-of-pocket amount. We looked at this the file, the Plans rules, and Medicare rules. The maximum out-of-pocket amount falls 
within the What is The Most You Will Pay for Medicare Part A and Part B Covered Medical 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 has properly assessed the maximum out-of-pocket amount for medical services provided 
from November 2, 2021, to November 30, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility (SNF) stay 
provided from February 1, 2022, to March 15, 2022. 
 
You asked the Plan to waive the copayment for the SNF stay. You say that you were told that you would be 
covered for the first 100 days. The Plan denied your request. The Plan says the copayment was applied 
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 $0 
copayment per day for days 1- 20: a $188 copayment per day for days 21-100.  
 
You have been asked to pay $4,995.63 for the SNF stay. The SNF stay falls within the Skilled Nursing Facility 
(SNF) 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 a skilled nursing facility 
(SNF) stay provided from February 1, 2022, to March 15, 2022.