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

 
We decided that the Plan does not have to waive the $5 copayment for an office visit on February 15, 2022. 
 
You asked the Plan to waive the $5 copayment for the office visit. You say that you should not be responsible 
for this copayment because this was an annual wellness visit. The Plan denied your request. The Plan says you 
must pay a $5 copayment for each in-network Primary Care Provider visit. 
 
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 $5 
copayment for Physician/Practitioner Services, Including Doctor's Office Visits.  
 
You have been asked to pay a $5 copayment for an office visit. An office 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. Records submitted support this was an office visit 
to establish care and discuss medical issues. Therefore, we decided that the Plan does not have to waive the $5 
copayment for an office visit on February 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
December 27, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you were taken to 
the ER twice before without being admitted. You say that your family was unable to transport you a third time. 
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 $125 
copayment per day for ambulance services.  
 
You have been asked to pay a $125 copayment for the ambulance transportation. The ambulance transportation 
falls 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 
ambulance transportation provided on December 27, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (procedure code 99285) 
provided to the enrollee on February 3, 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 the documentation does not support the high complexity criteria required for these services. 
 
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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the reviewed documentation did 
not support the high complexity criteria required for the services submitted. The review has determined that the 
records did not support the level of care for CPT 99285 in this case. 
 
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 emergency department services (procedure code 99285) provided to the enrollee on February 3, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cardiovascular stress test (93017) 
provided on March 17, 2022. 
 
You asked the Plan to waive the copayment for the cardiovascular stress test. 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 $160 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $160 copayment for the cardiovascular stress test. Cardiovascular stress tests 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 a cardiovascular stress test (93017) provided on March 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for injection and specialists office visit on 
January 25, 2022, to March 04, 2022. 
 
You asked the Plan to waive the cost-sharing for injection and specialists office visit. You say that you should 
not be responsible for all of the member responsibility because all of the visits could have been done in one 
visit. 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 20% 
coinsurance for Medicare Part B drugs, primary care providers (PCP) office, specialists office, or pharmacy. 
These drugs are covered under Part B of Original Medicare. Members of our plan receive coverage for these 
drugs through our plan. Covered drugs include: Drugs that usually aren't self-administered by the patient and 
are injected or infused while you are getting physician, hospital outpatient, or ambulatory surgical center services. A $45 copayment for specialists office visit. Covered services include, but are not limited to: X-rays, 
Radiation (radium and isotope) therapy including technician materials and supplies, Surgical supplies, such as 
dressings, Splints, casts and other devices used to reduce fractures and dislocations, and Laboratory tests. The 
provider billed and allowed in the amount of $226.24. The Plan paid $180.99. $226.24 - $180.99 = $45.25 
coinsurance. There also were 6 visits with a specialist, resulting in the amount of $270. $45.25 + $270 = 
$315.25. Therefore, results in the total cost-sharing amount of $315.25. 
 
You have been asked to pay a 20% coinsurance and a $45 copayment for injection and each specialists office 
visit. Injection and specialists office visits fall within the Medicare Part B prescription drugs and 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-sharing for injection and specialists office visit on January 25, 2022, to March 04, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid coded 87631 
provided on January 10, 2022. 
 
You asked the Plan to pay for the infectious agent detection by nucleic acid. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 
billed. 
 
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 87631 is not supported in the medical record. Specifically, the submitted documentation 
indicates more than five targets. There is a more appropriate code to describe the services provided. Based on 
this information, we decided that Medicare rules for coverage of the infectious agent detection by nucleic acid 
have not been met. Therefore, we decided that the Plan does not have to pay for the infectious agent detection 
by nucleic acid coded 87631 provided on January 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 test purchased on January 4, 2022. 
 
You asked the Plan to pay for the at-home COVID-19 test. You say that you received a letter stating if you 
purchased a COVID-19 home test kit you would be reimbursed. The Plan denied your request. The Plan says 
these tests are unable to be approved because they were purchased before the Plan implemented coverage for 
OTC at-home COVID-19 tests. 
 
  The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the at-home 
COVID-19 test is an OTC item. However, the Plan offers a supplemental benefit for over-the-counter home 
COVID-19 tests purchased after February 1, 2022. These tests were purchased on January 4, 2022, which is 
before this benefit went into effect. Therefore, we decided that the Plan does not have to pay for the at-home 
COVID-19 test purchased on January 4, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) 
(G0299) and home health aide (HHA) services (G0156). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the originally approved 42 hours per week were excessive. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that in this case, 
you are medically stable without any recent hospitalizations or medical complications. The approved weekly 
hours of home health aide services allow for appropriate support and care. The documentation does not support 
that the additional hours are needed to provide adequate support. There is no indication that you have any skilled nursing needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve direct skilled nursing services of a registered nurse (RN) (G0299) and home health aide 
(HHA) services (G0156).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99205) provided on August 12, 2021. 
 
You asked the Plan to pay for the evaluation and management service. 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 dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the office visit (99205) provided on August 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for technetium and regadenoson injections 
provided on February 14, 2022. 
 
You asked the Plan to waive the coinsurance for the injections. You say that you do not agree with the 
coinsurance amount. 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 medical supplies, including chemical agents used in certain diagnostic procedures. 
 
Your contract with the Plan also clearly says that you must pay a 5% coinsurance for Part B drugs. 
 Drug Allowed Amount Coinsurance 
Technetium (contrast) $222.20 $44.44 (20%) 
Regadenoson $238.80 $11.94 (5%) 
Total:  $56.38 
 
You have been asked to pay a total of $56.38 for the injections. The technetium injection falls within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The regadenoson 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 technetium and regadenoson injections provided on February 14, 2022.
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 November 4, 2021, to November 30, 2021. 
 
You asked the Plan to waive the copayment for the SNF stay. You say that you were not aware of a copay. The 
Plan denied your request. The Plan says the copayment applies from days 21-27 and it 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). The enrollees contract with the Plan clearly says that enrollees 
must pay, for each Medicare-covered SNF stay, a $0 copayment per day for days 1-20, then a $184 copayment 
per day for days 21-100.  
 
The enrollee has been asked to pay $1,288 ($184 copay x 7 days) for the SNF stay. The SNF stay falls within 
the Skilled Nursing Facility (SNF) Care 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 a skilled nursing facility (SNF) stay provided from November 4, 2021, to November 30, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a physical therapy (PT) evaluation provided 
on March 23, 2022. 
 
You asked the Plan to waive the deductible for the PT evaluation. You say that you only got fitted for a brace 
and did not receive any treatment. The Plan denied your request. The Plan says the deductible amount was 
applied correctly. 
 
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 $750 deductible which applies to the PT evaluation.  
 
 
 
 
 
 
 
 
 
 
 The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
Rehabilitation Services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is 
$750 deductible which applies to outpatient rehabilitation services. This cost sharing is a contractual obligation 
that had not been met at the time the PT evaluation was received on March 23, 2022. Therefore, we decided 
that the Plan does not have to waive the deductible for a physical therapy (PT) evaluation provided on March 
23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (99214) provided on 
April 4, 2022. 
 
You asked the Plan to waive the copayment for the specialist office 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 $40 
copayment for Physician/Practitioner services, including doctors office visits, specifically specialist visits.  
 
You have been asked to pay a $40 copayment for the specialist office visit, the record indicates that this 
provider is not your primary care physician (PCP). 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 
specialist office visit (99214) provided on April 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the medical eye exam (92014) provided on 
March 22, 2022. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you believed this was a routine eye 
exam and would require a $0 copayment. The Plan denied your request. The Plan says this claim was processed 
correctly, and your copayment was assessed in accordance with your contract. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye 
provided by a specialist.  
 
You have been asked to pay a $45 copayment for the eye exam. The eye exam in this case was billed as a 
medical exam, and the medical records provided indicate that medical conditions (such as nuclear sclerosis and 
mild cataracts). This means that the eye exam falls within the outpatient physician services for the diagnosis 
and treatment of diseases and injuries of the eye benefit category, and in this case the exam was performed by a provider other than your primary care physician. 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 medical eye exam (92014) provided on March 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total knee arthroplasty (CPT code 27447 x2). 
 
You asked the Plan to pre-approve the total knee arthroplasty. You say that the service is necessary. The Plan 
denied your request. The Plan says the enrollee's most recent body mass index (BMI) is 41.8 in May 2022, and 
this is a very high weight for a total knee replacement. The Plan states they still do not have record of a 
completed course of supervised physical therapy. 
 
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 the total knee arthroplasty. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the detailed documentation is not evident regarding trial and failure of 
recent, reasonable, and comprehensive less invasive conservative care measures. The documentation does not 
indicate any failed courses of physical therapy. Additionally, there is a noted body mass index of 41.8 kg/m2. 
There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in 
this clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception. Therefore, the requested left total knee replacement, in 
this case, is 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 total knee arthroplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the total knee arthroplasty (CPT code 27447 x2).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 11, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. 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 March 11, 2022.