Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an oxygen concentrator (E1390) provided 
from February 28, 2021, to September 29, 2021. 
 
You asked the Plan to waive the copayment for the oxygen concentrator. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the coinsurance 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 Emergency care.  
 
 
  You have been asked to pay a 20% coinsurance for an oxygen concentrator (total allowed is $722.2 x 20% = 
$144.44). Oxygen concentrators fall within the Emergency 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 an oxygen concentrator (E1390) provided from February 28, 2021, to September 
29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on July 9, 2021.  
 You asked the Plan to pay for the testing services. You say that the physician ordered the specialized testing. 
The Plan denied your request. The Plan says predictive screening testing is not a Medicare benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
We looked at the file and the rules. The records show that the enrollee received a gene carrier screening test. 
The testing services were requested solely for screening purposes. Medicare does not cover this test solely for 
screening purposes. Therefore, we decided that the Plan does not have to pay for the lab testing services 
provided on July 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement continuous positive airway pressure 
machine (CPAP). 
 
You asked the Plan to pre-approve the machine. You say that this is medically necessary. The Plan denied your 
request. The Plan says the durable medical equipment (DME) company explained that machine is working fine. 
 
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 machine. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case.  
 Our physician reviewer found there is insufficient documentation to support that a new CPAP machine is 
medically necessary at this time. The enrollee's CPAP machine is reportedly working fine. It is noted that 
devices affected by the Phillips recall and less than five years of age are non-covered under Medicare. 
 
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 machine have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a replacement continuous positive airway pressure machine (CPAP).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on October 24, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the home visit. You say that the enrollee is an established patient and would like 
the claim reprocessed for payment. The Plan denied your request. The Plan says the rendering provider is an 
out-of-network provider and there was no referral from an in-network provider or an approved authorization. 
  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 a home visit provided on October 24, 2021, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a therapeutic injection procedure performed 
on November 11, 2021. We also decided that the Plan does not have to waive the coinsurance for medical 
supplies, lidocaine, triamcinolone, and an unclassified drug provided on November 11, 2021. 
 You asked the Plan to waive the copayment and coinsurance for the injection, medical supplies, and Part B 
drugs. You say that you should only be charged $100 for the services like your previous bills. The Plan denied 
your request. The Plan says the correct copayment and 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 $100 
copayment for surgery or other services at an outpatient hospital facility or ambulatory surgical center. 
 
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for medical supplies. 
 
Your contract with the Plan also clearly says that you must pay a 5% coinsurance for Part B drugs. 
 
Drug/Procedure Allowed Amount Copayment/Coinsurance 
Injection Procedure (62323) - $100 (copayment) 
Medical Supplies $35.94 $7.19 (20% coinsurance) 
Unclassified Drug (J3490) $5.15 $0.26 (5% coinsurance) 
Lidocaine (J2001) $8.12 $0.41 (5% coinsurance) 
Triamcinolone (J3301) $70.97 $3.55 (5% coinsurance) 
Total:  $111.41 
 
You have been asked to pay a $111.41 for the injection, Part B drugs, and supplies. The injection falls within 
the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers benefit category. The medical supplies fall within the Outpatient Diagnostic Tests and Therapeutic 
Services and Supplies benefit category. The Part B drugs 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 copayment for a therapeutic injection procedure 
performed on November 11, 2021. We also decided that the Plan does not have to waive the coinsurance for 
medical supplies, lidocaine, triamcinolone, and an unclassified drug provided on November 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided on September 16, 2021. 
 
You asked the Plan to pay for the self-administered drugs. You say that the claim was rejected for no 
authorization, but the medical records warrant the medical necessity of the services billed. You say that the 
medical documentation should be reviewed, and the claim processed for payment. The Plan denied your 
request. The Plan says the claim reprocessed to pay for the outpatient surgery services and the self-
administered drugs remain denied. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided on September 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on December 16, 2020. You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the code 
remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. The claim at issue in this case was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Based on this information, 
we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided 
that the Plan does not have to pay for the drug testing services provided on December 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for an eye exam and a ranibizumab injection 
(J2778, 92012) provided on October 19, 2021. 
 
You asked the Plan to waive the cost-sharing for the eye exam and a ranibizumab injection. 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 must pay a $50 
copayment for Vision care and a 20% coinsurance for Medicare Part B prescription drugs. 
 You have been asked to pay a $50 copayment for an eye exam and a 20% coinsurance for a ranibizumab 
injection (allowed is $1,592.35 x 20% = $318.47). Eye exams fall within the Vision care benefit category and 
ranibizumab injections 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 cost-sharing for an eye exam and a ranibizumab injection (J2778, 92012) provided 
on October 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0241U) provided October 2, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. This service was for screening purposes.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab services 
(0241U) provided October 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraspinal manipulative treatments (98943) provided 
from August 2, 2021, through November 4, 2021. 
 
You asked the Plan to pay for the extraspinal manipulative treatments (98943). You say that your benefits 
clearly state that chiropractic care for manual manipulation of the spine to correct subluxation is covered 
subject to a $20 copayment. The Plan denied your request. The Plan says procedure codes 98941 and 98940 
have been approved and procedure code 98943 is not a covered chiropractic service. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that CPT code 98943 is not for manual manipulation of the spine. Specifically, extraspinal 
manipulative treatments are for areas other than the spine. Therefore, we decided that the Plan does not have to 
pay for the extraspinal manipulative treatments (98943) provided from August 2, 2021, through November 4, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional computed tomography scan (74177) provided 
on November 9, 2021. 
 
You asked the Plan to pay for an additional computed tomography scan. You say that this was billed correctly. 
The Plan denied your request. The Plan says this was previously billed and paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that a second unit of CPT code 74177 is not supported in the medical record. The medical record only 
supports 1 unit of CPT code 74177, which was previously billed and paid. Based on this information, we 
decided that Medicare rules for coverage of an additional computed tomography scan have not been met. 
Therefore, we decided that the Plan does not have to pay for an additional computed tomography scan (74177) 
provided on November 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
October 26, 2021, to October 28, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that if you would have 
known there would be a charge of $360 for not remaining in the hospital six or more days, you would have 
remained there until your third surgery. 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 $360 
copayment per day for days 1-5 for an in-network inpatient hospital stay. There is a $0 copayment for days 6-90. There is no charge for the day of discharge. The Plan contract also says your inpatient cost share will begin 
on day one each time you are admitted for inpatient hospital care.  
 
The record shows the claim has been processed correctly and cost sharing would still apply for the first five 
days, even if you stayed in the hospital six days or more. You have been asked to pay a total of $720, which is 
a $360 copayment for a two-day inpatient hospital stay from October 26, 2021, to October 28, 2021 ($360 
copayment + $360 copayment = $720). There is no charge on the day of discharge. An inpatient hospital stay 
falls within the Inpatient Hospital 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 an inpatient hospital stay provided from October 26, 2021, to October 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive gene panel testing provided on July 15, 
2021. 
You asked the Plan to pay for the testing services. You say that the services were rendered in good faith. The 
Plan denied your request. The Plan says the screening testing is not a Medicare benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing services were requested solely for screening purposes. Medicare does not cover this testing for 
screening purposes. Therefore, we decided that the Plan does not have to pay for the comprehensive gene panel 
testing provided on July 15, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to increase the reimbursement for psychotherapy services provided 
from January 7, 2021, to April 29, 2021. 
 
You asked the Plan to increase the reimbursement for the psychotherapy services. You say that you were 
reimbursed less that the correct amount. The Plan denied your request. The Plan says you have been 
reimbursed the correct 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 $15 
copayment for each visit at a specialist's office. 
 
 
 Service Date Allowed Amount Copayment Plan Responsibility 
January 7, 2021 $131.98 $15.00 $116.98 
January 21, 2021 $131.98 $15.00 $116.98 
February 4, 2021 $131.98 $15.00 $116.98 
February 18, 2021 $131.98 $15.00 $116.98 
March 4, 2021 $131.98 $15.00 $116.98 
March 18, 2021 $131.98 $15.00 $116.98 
April 1, 2021 $131.98 $15.00 $116.98 
April 15, 2021 $131.98 $15.00 $116.98 
April 29, 2021 $131.98 $15.00 $116.98 
Total:  $135.00 1,052.82 
 
The Plan can only reimburse the difference between the Medicare allowed amount and your copayment 
amount. In this case, the Plan has correctly reimbursed $1,052.82 for the 9 visits, with your remaining 
responsibility of $135 for your copayments. Please note that the Plan cannot reimburse costs in excess of the 
Medicare allowed amount. The psychotherapy services fall within the Outpatient Mental Health Care benefit 
category. This means that you have been reimbursed the correct amount based on your contract with the Plan. 
Therefore, we decided that the Plan does not have to increase the reimbursement for psychotherapy services 
provided from January 7, 2021, to April 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for parenteral nutrition solution (B4197) provided on June 5, 
2021. 
 
You asked the Plan to pay for parenteral nutrition solution. You say that this is supported in the records. The 
Plan denied your request. The Plan says this cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for parenteral nutrition to be considered 
reasonable and necessary, the treating practitioner must document that enteral nutrition has been considered 
and ruled out, tried and been found ineffective, or that enteral nutrition exacerbates gastrointestinal tract 
dysfunction. The beneficiary must have either a condition involving the small intestine and/or its exocrine 
glands which significantly impairs the absorption of nutrients, or a disease of the stomach and/or intestine 
which is a motility disorder and impairs the ability of nutrients to be transported through and absorbed by the gastrointestinal (GI) system. 
 
We looked at the file and Medicare rules. The submitted records do not document why enteral nutrition is not 
an option for the enrollee. The records also do not document that the enrollee has a permanent condition 
requiring parenteral nutrition. Based on this information, we decided that Medicare rules for coverage of 
parenteral nutrition solution have not been met. Therefore, we decided that the Plan does not have to pay for 
parenteral nutrition solution (B4197) provided on June 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a disposable filter for a continuous positive 
airway pressure (CPAP) machine provided on September 28, 2021. 
 
You asked the Plan to waive the deductible for the CPAP filter. You say that you feel your deductible was met 
before this claim. 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 $600 deductible which applies to certain items and services.  
 
The CPAP filter you asked the Plan to waive the deductible for falls within the Durable Medical Equipment 
(DME) and Related Supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in 
the contract that there is $600 deductible which applies to Durable Medical Equipment (DME) and Related 
Supplies. This cost sharing is a contractual obligation that had not been met at the time the CPAP filter was received on September 28, 2021. Please note that deductible amounts are processed in the order the claims are 
received by the Plan. Therefore, we decided that the Plan does not have to waive the deductible for a disposable 
filter for a continuous positive airway pressure (CPAP) machine provided on September 28, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound of behind the abdominal 
cavity provided on November 8, 2021. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you want to know why this 
ultrasound is not covered as it was ordered by your urologist. 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 $160 
copayment for in-network radiological diagnostic services, including ultrasounds at a free-standing facility.  
 
 You have been asked to pay the allowed amount of $104.12, which is less than the $160 copayment for an 
ultrasound. An ultrasound 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 ultrasound of behind the 
abdominal cavity provided on November 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
thorax provided on August 10, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you feel insurance did not pay 
enough on the claim. 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 $110 
copayment for diagnostic radiology services, including CT scans.  
 
You have been asked to pay a $110 copayment for the CT scan. Please note that the Plan covers costs in excess 
of your copayment amount. The CT scan 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 computed tomography 
(CT) scan of the thorax provided on August 10, 2021.