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

 
We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy (43239) 
provided on December 8, 2021. 
 
You asked the Plan to waive the copayment for the esophagogastroduodenoscopy. You say that the services 
should be covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-
sharing applied correctly based on the services provided. 
 
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 surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 You have been asked to pay a $275 copayment for an esophagogastroduodenoscopy. 
Esophagogastroduodenoscopies fall 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 an esophagogastroduodenoscopy (43239) provided on December 8, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on December 11, 2021. 
 
You asked the Plan to pay for the medical services. You say that the patient was discharged from hospice prior 
to these services. The Plan denied your request. The Plan says the patient was enrolled in hospice on the date of 
service. 
 
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Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.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 December 6, 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 medical services 
provided on December 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the 
brain stem provided on January 19, 2022. 
 
You asked the Plan to waive the copayment for the MRI. You say that you have had MRI's in the past with a 
lower 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 $325 
copayment for diagnostic radiology services, including MRI's.  
 
You have been asked to pay $275.09, which is less than the $325 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 the copayment for a magnetic resonance imaging (MRI) of the brain stem provided on 
January 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
You asked the Plan to waive the copayment for the office visit. You say that the services should be covered as 
you disagree with the specialist copayment. The Plan says that the cost-sharing applied correctly based on the 
services provided. 
 
  We decided that the Plan has to reduce the copayment for the office visit.  
 
The Plan follows Medicare rules. Medicare rules say that 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 an office visit with your primary care provider, the 
Plan has not included information that supports a specialist provided these services, therefore we have decided 
that the Plan must reduce your copayment from the specialist $30 copayment to the PCP $20 copayment. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on September 5, 
2021. 
 
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 is included in the global package. 
 
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 44310 is Ileostomy or jejunostomy, non-tube. 
 
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 the provider billed abdominal surgical 
services performed on August 24, 2021 with a global period of 90 days. In this case, CPT 44310 is a related 
procedure, and therefore would be considered part of the global package. 
 
  
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 surgical services provided to the enrollee on September 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-transport ambulance services you received on October 
26, 2021. 
 
You asked the Plan to pay for the non-transport ambulance services. You say that you fell through a glass table 
and your arm was bleeding.  The ambulance was called, and they checked you, but your bleeding was under 
control. The Plan denied your request. The Plan says non-transport ambulance services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 26, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for non-transport ambulance services you received on 
October 26, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on August 17, 2021. 
 
You asked the Plan to pay for the medical services. You say that you have provided medical records to support 
payment for this service. The Plan denied your request. The Plan says it is not responsible for these services 
because the enrollee was in hospice on the date of service in question. 
 
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 medical services provided on August 17, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the hearing aids you purchased from the Plan's designated hearing aid 
vendor on October 18, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that you were told that these were the hearing aids you 
needed.  You said that the vendor did not present you with covered options. The Plan denied your request. The 
Plan says that the hearing aids purchased are not on the Plan's formulary and are therefore not covered. 
 
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 specific hearing aids 
you purchased are not on the Plan's formulary. The Plan has provided no formulary to us in the case file 
submitted.  The Plan did provide a copy of the Evidence of Coverage, which states that only the hearing aid 
types listed a covered.  However, the Plan has failed to provide any documentation defining the difference 
between the different levels of hearing aids listed.  The Plan has also failed to provide a listing of the specific 
hearing aids and brands that would fall into each of the listed hearing aid type categories.  Without this 
information, we cannot determine if the hearing aids you purchased do or do not fall within one of these 
covered categories. Therefore, we decided that the Plan has to pay for the hearing aids you purchased from the 
Plan's designated hearing aid vendor on October 18, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation (A0427) 
provided on January 5, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the services should 
be covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing 
applied correctly based on the services provided. 
 
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 $270 
copayment for Ambulance Services.  
 
 
  You have been asked to pay a $270 copayment for ambulance transportation. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for ambulance transportation (A0427) provided on January 5, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for psychotherapy services provided on 
January 7, 2022. 
 
You asked the Plan to waive the copayment for the psychotherapy services. You say that you don't agree with 
being charged a specialist copayment each time when you do not see the actual 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 $40 
copayment for each mental health session.  
 
You have been asked to pay a $40 copayment for the psychotherapy services. The psychotherapy services fall 
within the Outpatient Mental Health 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 psychotherapy services provided on January 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Medicare Part B drug injection 
provided on December 20, 2021. 
 
You asked the Plan to waive the coinsurance for the Medicare Part B drug injection. You say that you were not 
told the total cost that you would have to pay. The Plan denied your request. The Plan says the coinsurance 
amount charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for other Medicare-covered Part B drugs.  
 
 
 You have been asked to pay $2,681.50, which is 20% coinsurance of the allowed amount ($13,407.50) for the 
Medicare Part B drug injection. Medicare Part B drug 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 the Medicare Part B drug 
injection provided on December 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for eyeglasses you purchased at Costco on December 9, 
2021. 
 
You asked the Plan to pay more for the eyeglasses. You say that you believe you are entitled to $150 towards 
eyeglasses and you were only reimbursed a portion of that. The Plan denied your request. The Plan says you 
were reimbursed appropriately because you did not use the Plan's designated vision vendor. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan contract says that if you use the Plan's designated vision care vendor, you have the benefit 
of $150 per calendar year for eyeglasses.  If you use any provider other than the Plan's designated vision 
vendor, you will be reimbursed up to $90 for eyeglasses. The provider from whom you purchased this 
eyeglasses is not the Plan's designated vision vendor.  As a result, the Plan reimbursed you $90 for these 
eyeglasses appropriately. 
 
Therefore, we decided that the Plan does not have to pay more for eyeglasses you purchased at Costco on 
December 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a tildrakizumab injection provided on 
January 18, 2022. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you were not made aware of the 
cost before the procedure. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for each Part B drug.  
 You have been asked to pay $2,681.50, which is 20% of the allowed amount for the injection ($13,407.50 
allowed amount x 20% coinsurance = $2,681.50). 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 a tildrakizumab injection 
provided on January 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a telehealth visit provided on December 8, 
2021. 
 
You asked the Plan to waive the copayment for the telehealth visit. You say that the services should be covered 
as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 Physician/Practitioner services, including doctors office visits.  
 
 
  You have been asked to pay a $50 copayment for a 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 a telehealth visit provided on December 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cardiac rehabilitation services provided on 
December 20, 2021. 
 
You asked the Plan to waive the copayment for the cardiac rehabilitation. You say that you should not have a 
copayment for these services. 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 cardiac rehabilitation services.  
 
You have been asked to pay a $20 copayment for the cardiac rehabilitation. The cardiac rehabilitation falls 
within the Cardiac Rehabilitation 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 cardiac rehabilitation services provided on December 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99243 billed for date of service November 5, 
2021. 
 
You asked the Plan to pay for procedure code 99243. You say that you have submitted a corrected claim. The 
Plan denied your request. The Plan says this is not a Medicare-payable code. 
 
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 99243 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code 99243 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code 99243 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99243 billed for date of service November 5, 2021.  
 
You stated that you filed a new, corrected claim with procedure code 99203.  We have no evidence that the 
Plan has denied payment for that code, so that issue is not currently within our jurisdiction.  If the Plan has not 
yet issued a denial of this code, that is an issue that must be answered by the Plan. Medicare does not permit us 
to make a decision about these types of issues until the Plan denies the new claim.  Please contact the Plan 
directly with any questions regarding your new claim submission with code 99203.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on January 15, 2022. 
 
You asked the Plan to pay for the medical services. You say that you billed with the correct place of service. 
The Plan denied your request. The Plan says you billed with an incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill the appropriate place of 
service on their claims.  Place of service 21 should be used for inpatient hospital.  Place of service 22 should be 
used for outpatient hospital.  Records show that you billed with Place of Service 22.  However, claim records 
show that the patient was in an inpatient hospital stay on the date of service in question.  Therefore, Place of 
Service 21 should have been entered on the claim. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided on January 15, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for brachytherapy services (C2616) provided 
September 22, 2021. 
 
You asked the Plan to waive the coinsurance for THE brachytherapy services. You say that the services should 
be covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing 
applied correctly based on the services provided. 
 
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 Prescription Drugs.  
 
 
  You have been asked to pay a 20% coinsurance for brachytherapy services, your maximum out-of-pocket is 
less than the 20% coinsurance based on the allowed amount, therefor you have only been asked to pay a 
$1,808.89 coinsurance. Brachytherapy services fall 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 brachytherapy services (C2616) provided 
September 22, 2021.