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

 
We decided that the Plan does not have to waive the cost sharing for lab services and office visit on May 20, 
2022. 
 
You asked the Plan to waive the cost sharing for lab services and office visit. You say that you want to appeal 
the amount being charged. The Plan denied your request. The Plan says the cost sharing you are being charged 
is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 50% 
coinsurance for each Medicare-covered lab service. Covered services include but are not limited to laboratory 
tests. You must pay a $55 copayment for Medicare-covered primary care physician (PCP) services (including 
Medicare-covered telehealth services and urgently needed services). Covered services include consultation, 
diagnosis, and treatment by a specialist. The provider billed in the following amounts: $58 and the allowed 
amount is $8.25. $8.25 x 50% = $4.13. Billed amount of $44 and the allowed amount is $6.60. $6.60 x 50% = 
$3.30. Billed amount of $165 and the allowed amount is $8.98. $8.98 x 50% = $4.49. Billed in the amount of 
$82.50 and the allowed amount is $11.38. $11.38 x 50% = $5.69. Billed in the amount of 78 and the allowed 
amount is $7.67. $7.67 x 50% = $3.84. Billed in the amount of $110 and the allowed amount is $14.28. $14.28 
x 50% = $7.14. $4.13 + $3.30 + $4.49 + $5.69 + $3.84 + $7.14 = $28.59. $55 + $28.59 = $83.59. 
 
You have been asked to pay a 50% coinsurance for lab services and $55 copayment office visit. Lab services 
and office visits fall within the Outpatient diagnostic tests and therapeutic services and supplies and 
Physician/Practitioner services, including doctor's office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the cost sharing for lab services and office visit on May 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64483 billed for date of service January 5, 
2022. 
 
You asked the Plan to pay for procedure code 64483. You say that the claim should be reprocessed. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
  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 64483 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. One unit of procedure code 64483 has already been paid. Based on this information, 
we decided that Medicare rules for coverage of an additional unit of procedure code 64483 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 64483 billed for date of service 
January 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on July 8, 2021, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the wound care. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 
wound care. We found no exception that would require the Plan to pay for the wound care. The records 
provided for review do not show that the wound care was urgent or emergent. Therefore, we decided that the Plan does not have to pay for wound care provided on July 8, 2021, by an out-
of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical equipment provided on May 19, 2021. 
 
You asked the Plan to pay for the medical equipment. You say that you believe the time frame for filing should 
be extended. The Plan denied your request. The Plan says you did not timely file your claim. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the medical equipment was not filed until June 7, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for medical equipment provided on May 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dialysis treatments provided on January 1, 2022, to January 
31, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for dialysis treatments. You say that the services were medically necessary, and the 
absence of an authorization for these dates of service was inadvertent. The Plan denied your request. The Plan 
says no prior authorization was obtained. 
 
 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 
dialysis treatments. We found no exception that would require the Plan to pay for the dialysis treatments. The 
records provided for review do not show that the dialysis treatments were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for dialysis treatments provided on January 1, 2022, to January 31, 
2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cataract surgery provided on March 28, 
2022. 
 
You asked the Plan to waive the copayment for cataract surgery. You say that you were charged for items that 
you should not have to pay for. The Plan denied your request. The Plan says coinsurance 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 $250 
copayment for each Medicare-covered surgery at an outpatient hospital facility.  
 
You have been asked to pay $250 copayment for cataract surgery. The cataract 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 cataract surgery provided 
on March 28, 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 28, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 
 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 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service May 11, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service May 11, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on March 
26, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that the copayment should be 
waived because it was not your decision to travel in the ambulance. 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 $350 
copayment per one-way trip for ambulance services.  
 
You have been asked to pay a $350 copayment for the ambulance services. The ambulance services fall within 
the Ambulance Services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
ambulance services provided on March 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit, nail trimming, and nail debridement provided 
on February 28, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit, the nail trimming, and the nail debridement. You say that the 
enrollee misled the office of incorrect insurance, therefore the office was unable to obtain authorization. The 
Plan denied your request. The Plan says no prior authorization was obtained. 
 
 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 
office visit, the nail trimming, and the nail debridement. We found no exception that would require the Plan to 
pay for the office visit, the nail trimming, and the nail debridement. The records provided for review do not 
show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to 
pay for the office visit, nail trimming, and nail debridement provided on February 28, 2022, by an out-of-
network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray provided on May 10, 2020. 
 
You asked the Plan to pay for the chest x-ray. You say that you believe this claim was timely filed. The Plan 
denied your request. The Plan says you did not timely file this corrected claim. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the chest x-ray was not filed until April 29, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the chest x-ray provided on May 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a primary care (PCP) office visit provided 
on April 19, 2022. 
 
You asked the Plan to waive the copayment for the PCP visit. You say that this was your annual visit and 
should not have a copayment. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay no 
coinsurance, copayment, or deductible for the annual wellness visit. If you receive services that address a 
medical condition during the same office visit, additional cost sharing may apply. 
 Your contract with the Plan also clearly says that you must pay a $10 copayment for each visit with your PCP. 
 
The records show that during this visit, specific concerns were addressed, including osteoporosis, dyslipidemia, 
and osteoarthritis. These topics go beyond the scope of the annual wellness visit and are subject to copayment. 
Therefore, you have been asked to pay a $10 copayment for the PCP visit. The PCP visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a primary care (PCP) office visit provided on April 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on April 8, 2022. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you are appealing the coinsurance 
assessed on the injection. The Plan denied your request. The Plan says you have been charged the correct 
coinsurance 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% 
coinsurance for Medicare Part B chemotherapy drugs and other Part B drugs.  
 
 
 
 
 You have been asked to pay a 20% coinsurance for an injection. The injection 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 an injection 
provided on April 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from long-
term acute care due to medical complexity. The Plan denied your request. The Plan says rules for LTACH care 
have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving care. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiography provided on June 
10, 2022. 
 
You asked the Plan to waive the copayment for an electrocardiography. You say that you expected this 
copayment but the staff at the hospital told you that you did not have one. Therefore, you would like it 
removed. The Plan denied your request. The Plan says the copayment that was 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 $100 
copayment for other outpatient diagnostic tests (such as nerve conduction studies, electroencephalogram (EEG) 
and electromyography).  
 
You have been asked to pay a $100 copayment for an electrocardiography. An electrocardiography 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 electrocardiography provided on June 10, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the nuclear medicine studies provided on 
May 11, 2022. 
 
You asked the Plan to waive the copayment for the nuclear medicine studies. You say that you paid a $45 
copayment on the date of the procedure, and your authorization notice should have stated the correct amount. 
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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $250 copayment for diagnostic radiology service other than CT scans.  
 
The enrollee has been asked to pay a $250 copayment for the nuclear medicine studies. The nuclear medicine 
studies fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. 
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This 
cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the nuclear medicine studies provided on May 
11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 7, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept (A0432) services provided on 
February 2, 2022. 
 
You asked the Plan to pay for the paramedic intercept services. You say that you do not feel it is right to have 
to pay for this service when the enrollee was in need of the provided medical treatment. The Plan denied your 
request. The Plan says the enrollee's coverage does not provide for this ambulance service. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York.  
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept (A0432) services provided on February 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for finger X-rays provided on May 9, 2022. 
 
You asked the Plan to waive the copayment for the X-rays. You say that you were informed you would not 
have a copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for basic radiological services, including X-rays, provided at a specialist's office. 
 
You have been asked to pay a $25 copayment for the X-rays. The X-rays 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 copayment 
for finger X-rays provided on May 9, 2022.