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

 
We decided that the Plan does not have to pre-approve Libtayo. 
 
You asked the Plan to pre-approve Libtayo. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Libtayo. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the NCCN Guidelines does not support the 
use of systemic therapy for local disease (including multiple primaries) in patients amenable to curative 
surgery. Systemic therapy is only recommended for locally advanced disease when radiation and surgery are 
not feasible. From the documentation it is unclear if this enrollee has locally advanced disease and no local 
treatments have been tried. Surgery and radiation are feasible and likely safer and more effective than systemic 
treatment. The service is not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Libtayo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Libtayo.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services rendered on January 20, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the claim was not billed with the required DEX-Z code. 
 
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 states that the claim was not billed with the required DEX-Z code, per 
Local Coverage Determination (LCD) L35025; however, this LCD is not valid for the state of Massachusetts 
where the testing is performed. The Plan has not provided any documentation or Medicare rules to support that 
the testing is not covered. Therefore, we decided that the Plan has to pay for the laboratory services rendered on 
January 20, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service January 12, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that the Plan should reconsider payment for this 
code. The Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service January 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a wheelchair and accessories provided 
from January 31, 2022, to February 28, 2022. 
 
You asked the Plan to waive the coinsurance for a wheelchair and accessories. You say that this price is too 
high, and you cannot afford it. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for durable medical equipment (DME) and related supplies.  
($130.85 x 20% = $26.17) + ($933.07 x 20% = $126.33) + ($116.42 x 20% = $23.40) + ($82.30 x 20% = 
$16.46) = $192.36. 
 
You have been asked to pay a $192.36 coinsurance for a wheelchair and accessories. A wheelchair and 
accessories fall 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 wheelchair and accessories provided from 
January 31, 2022, to February 28, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 27, 2022. 
 
You asked the Plan to pay for the lab services. You say that the plan is required to pay for services that are 
covered for Part B enrollees. The Plan denied your request. The Plan says original Medicare is responsible for 
payment. 
 
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 lab services provided on January 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a home health certification provided on 
December 29, 2021. 
 
You asked the Plan to waive the copayment for the home health certification. You say that you received a bill 
from an unknown doctor. 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 $20 
copayment for specialist services.  
 
The file shows that the provider completed the assessment and certification for home health care on December 
29, 2021. Therefore, you have been asked to pay a $20 copayment for the home health certification. The home 
health certification 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 home health certification provided on 
December 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transport rendered on December 7, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the billed diagnosis code is not appropriate. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with an appropriate 
laterality diagnosis code. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance 
transport rendered on December 7, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, conventional air services, transport, 
one way (A0431), and rotary wing air mileage (A0436) provided on August 26, 2021. 
 
You asked the Plan to pay for the air ambulance services. You say that the enrollee required rapid transport to a 
facility with gastrointestinal (GI) services immediately available. You say that the air ambulance requested for rapid transport to definitive care and the availability to initiate blood administration as needed. The Plan denied 
your request. The Plan says the air ambulance services were not medically necessary. 
 
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 air ambulance services. Our reviewer 
says that the air ambulance services were not medically necessary. Our physician reviewer found the provided 
documentation indicates that a facility capable of caring for the enrollee was available less than two miles from 
the enrollee's location. The reviewer found that the enrollee could have been provided by ground ambulance to 
that facility. The record does not indicate the medical necessity of transporting the enrollee to the facility to 
which she was transported by air ambulance. Therefore, the reviewer found that the air ambulance services 
were not medically reasonable or necessary. 
 
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 air ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for the ambulance service, conventional air services, transport, one way (A0431), and 
rotary wing air mileage (A0436) provided on August 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a dermatology visit provided on March 29, 
2022. 
 
You asked the Plan to waive the copayment for a dermatology visit. You say that you should not have to pay 
this copayment. The Plan denied your request. The Plan says the copayment 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 $30 
copayment for Physician/Practitioner services.  
 
You have been asked to pay a $30 copayment for a dermatology visit. A dermatology visit falls within the 
Physician/Practitioner 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 a 
dermatology visit provided on March 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for laboratory services provided on March 22, 
2022. 
 
You asked the Plan to waive the deductible for the lab services. You say that you were under the impression 
that all diabetes care is covered. The Plan denied your request. The Plan says the correct amount was applied to 
your deductible. 
 
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 $390 deductible which applies to certain items and services.  
 
The lab services fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $390 
deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not 
been met at the time the lab services were received on March 22, 2022. Therefore, we decided that the Plan 
does not have to waive the deductible for laboratory services provided on March 22, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services rendered on February 10, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on [Please enter the date on which the prior claim was paid (from remittance)]. 
Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that 
the billed items/services were provided twice on the same date. Based on this information, we decided that the 
Medicare rules for these services have not been met. Therefore, we decided that the Plan does not have to pay 
for the emergency room (ER) services rendered on February 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient visit provided on January 24, 2022. 
 
You asked the Plan to pay for an outpatient visit. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an outpatient visit provided on January 24, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services 
provided from January 1, 2022, to January 5, 2022. 
 
You asked the Plan to waive the copayment for SNF services. You say that you do not understand why you 
were not discharged so you wouldn't have to pay for additional days. The Plan denied your request. The Plan 
says the copayment 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 and a $188 copayment per day for days 21-100.  
 
You have been asked to pay $564 ($188 copay x 3 days) for SNF services. SNF services fall 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 skilled 
nursing facility (SNF) services provided from January 1, 2022, to January 5, 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 16, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like this claim 
reprocessed based on the medical records. 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 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tissue exam (88305) provided on April 7, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the tissue exam. You say that the enrollee was changed to a PPO plan starting 
5/1/2022, but nothing was done for the date of service 4/7/2022. The Plan denied your request. The Plan says 
the services were provided out-of-network and were not approved in advance. 
 
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 tissue exam (88305) provided on April 7, 
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 cost for the IV therapy, inpatient stay and diagnostic 
services provided from January 3, 2022, through April 20, 2022. 
 
You asked the Plan to waive the cost for the IV therapy, inpatient stay, and diagnostic services. You say that 
you cannot afford the bills. The Plan denied your request. The Plan says the claims 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). Your contract with the Plan clearly says that you must pay a $330 
copayment per day, for days 1-5 for inpatient hospital care, a $20 copayment for Medicare-covered x-rays, a 
$300 copayment for Medicare-covered advanced imaging and 20% coinsurance for Medicare-covered IV 
infusion therapy. 
 
You have been asked to pay a total of $1,230.79 for the IV therapy, inpatient stay, and diagnostic services.  
 
Date of Service Service Allowed Amount Cost Per Contract Member Liability 
January 3, 2022 & 
January 19, 2022 
IV therapy $453.88 20% $90.77 
January 25, 2022- 
January 28, 2022 
Inpatient Stay $23,890.93 $330/day $990 
March 23, 2022 X-Ray $33.18 $20 $20 
April 7, 2022 CT Scan $110.02 $300 $110.02 
April 20, 2022 X-Ray $33.18 $20 $20 
TOTAL:    $1,230.79 
 
The IV therapy falls within the Outpatient Hospital Services benefit category. The inpatient stay falls within the 
Inpatient Hospital Care benefit category. The x-rays and CT scan fall 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 cost for the 
IV therapy, inpatient stay and diagnostic services provided from January 3, 2022, through April 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a mastectomy bra (L8000), mastectomy 
form (L8020), and breast prosthesis (L8030) provided on January 19, 2022. 
 
You asked the Plan to waive the coinsurance for durable medical equipment. You say that the items do not fit 
and you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing 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 20% 
coinsurance for Medicare-covered durable medical equipment. 
 
You have been asked to pay a 20% coinsurance for each mastectomy and breast prosthetic item. The items at 
issue fall within the Durable Medical Equipment (DME) and related supplies benefit category. Please see the 
breakdown of your cost-share on the following page. 
 
 
 L8000: Allowed Amount $109.52  20% = $21.90 
L8020: Allowed Amount $187.64  20% = $37.53 
L8030: Allowed Amount $242.85  20% = $48.57 
Total: $108.00 
 
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 mastectomy bra (L8000), mastectomy form (L8020), and 
breast prosthesis (L8030) provided on January 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the copayment for a magnetic resonance imaging 
(MRI) of the lumbar spine provided on February 26, 2022. 
 
You asked the Plan to waive or reduce the copayment for the MRI. You say that you paid more for the service 
than the Plan did. 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 $300 
copayment for complex radiology services, including MRI's.  
 
You have been asked to pay a $300 copayment for the MRI. The MRI 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 or reduce the 
copayment for a magnetic resonance imaging (MRI) of the lumbar spine provided on February 26, 2022.