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

 
We decided that the Plan does not have to waive the copayments for outpatient surgeries provided on 
September 2, 2020, and February 17, 2021. 
 
You asked the Plan to waive the copayments for outpatient surgeries. You say that this should only be an office 
visit copayment. The Plan denied your request. The Plan says the copayment applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for each in-network outpatient hospital and observation service.  
 
 
 
 
 
 
 You have been asked to pay a $100 copayment for outpatient surgeries ($50 x 2 visits = $100). Outpatient 
surgeries fall within the in-network Outpatient Hospital and Observation Service 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 copayments for outpatient surgeries provided on September 2, 2020, and February 
17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the services the enrollee needs can be provided safely in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. You 
have multiple comorbidities and would benefit from close medical monitoring. Evaluating therapists most 
recent documentation states you would not tolerate intense therapy and recommend skilled nursing facility care. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to waive the refund request for the ambulance service, basic life 
support, non-emergency transport (A0428) and ground mileage (A0425) provided on December 1, 2021. 
 
You asked the Plan to waive the refund request for the ambulance services. You say that the enrollee was not 
on hospice at the time of the transfer. The Plan denied your request. The Plan says [Enter plan denial rationale, 
e.g. "...rules for SNF care have not been metthe 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. The 
Medicare hospice benefit is applied by the date it is elected and is not time specific. Therefore, we decided that 
the Plan does not have to waive the refund request for the ambulance service, basic life support, non-
emergency transport (A0428) and ground mileage (A0425) provided on December 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on March 11, 
2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you told the hospital you 
didn't want to be transferred if there was going to be a charge. The Plan denied your request. The Plan says the 
copayment applied 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 $125 
copayment per one-way trip for Medicare-covered ambulance services.  
 
  
 
You have been asked to pay $125 copayment for ambulance transport. Ambulance transport 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 transport 
provided on March 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is willing to participate in an intensive 
rehabilitation program in hopes of regaining lost function and increasing her safety. You say that the enrollee 
meets full inpatient rehab criteria based on CMS guidelines and her needs cannot safely be met at a lower level 
of care. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria. 
 
  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee continues to have a need for skilled therapy; however, the 
documentation does not support that she would meet criteria for admission to an acute inpatient rehabilitation 
facility. The enrollee can receive further services at a lower level of 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient rehabilitation care provided from 
March 8, 2022, to March 15, 2022. 
 
You asked the Plan to waive the copayment for the inpatient rehab. You say that the enrollee was not aware 
that transferring to a rehab facility was considered a new admission. The Plan denied your request. The Plan 
says the enrollee has 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 $350 per day for days 1-5 and $0 per day after day 5 for each admission, including transfers to a 
separate facility type.  
 
The file shows the enrollee was in the rehab facility from March 8, 2022, to March 15, 2022. Therefore, the 
enrollee has been asked to pay $350 per day for the first 5 days of inpatient rehab. The total for the stay is 
$1,750 ($350 copayment x 5 days = $1,750). The inpatient rehab falls within the Inpatient Hospital 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 inpatient rehabilitation care 
provided from March 8, 2022, to March 15, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy drugs provided on February 
17, 2022. 
 
You asked the Plan to waive the coinsurance for chemotherapy drugs. You say that you cannot afford these 
bills. The Plan denied your request. The Plan says the coinsurance applied 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 chemotherapy drugs.  
 
 
 
 
 
 
 
 You have been asked to pay $2,625.73 which is 20% of the allowed amount for chemotherapy drugs.  
 
Date of Service Service Allowed Amount Coinsurance Member Liability 
February 17, 2022 Chemotherapy 
Drugs 
$62.37 20% $12.47 
February 17, 2022 Chemotherapy 
Drugs 
$320.75 20% $64.15 
February 17, 2022 Chemotherapy 
Drugs 
$40,243.46 20% $2,549.11 
Total:    $2,625.73 
 
Chemotherapy 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 coinsurance for chemotherapy drugs provided on February 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical pathology services provided on December 13, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for surgical pathology services. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says this provider is not a network provider with the Plan. The 
Plan also says that they have also determined that these services are not urgent or emergent, nor were they 
approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan 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 surgical pathology services provided on December 
13, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the 4 at-home coronavirus test kits purchased on 
January 6, 2022. 
 
You asked the Plan to reimburse you for the coronavirus test kits. You say that you got a denial for the 
coronavirus test kits. You also say that this should be covered. The Plan denied your request. The Plan says the 
benefit for this service was not effective until February 15, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the coronavirus test kits have not been met. Therefore, we decided that the Plan does not have to 
reimburse you for the 4 at-home coronavirus test kits purchased on January 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing coded as 
81439, 81286, 81410, 81411 and 81479 provided February 23, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that please find the attached appeal and process 
the claim towards payment. The Plan denied your request. The Plan says genetic cardiovascular screening 
testing does not meet the definition of cardiovascular disease screenings. 
 
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, the laboratory services, 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 cardiac risk assessment genetic screening testing coded as 81439, 81286, 81410, 81411 and 81479 provided 
February 23, 2021.
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 10, 
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 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 81225, 81227, 81230, 
81231, 81232, 81291, 81306, 81355, 81335, 0031U, 0032U, 0033U, 81407, 81238 provided February 3, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you believe that the treatment sought is 
medically necessary to treat the enrollee based on the enrollee's medical condition. The Plan denied your 
request. The Plan says does not meet Medicare NCD/LCD criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We looked at this the file and Medicare rules. Outreach to the providers indicated on the claim verified that the 
provider did not order the test and no genetic testing was done by the doctor. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided 
that the Plan does not have to pay for the laboratory services coded as 81225, 81227, 81230, 81231, 81232, 
81291, 81306, 81355, 81335, 0031U, 0032U, 0033U, 81407, 81238 provided February 3, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $90 copayment for an emergency room visit on March 31, 
2022. 
 
You asked the Plan to waive the $90 copayment for an emergency room visit. You say that you feel you are not 
responsible for this copayment because you were hurt due to negligence. The Plan denied your request. The 
Plan says you must pay a $90 copayment per emergency room 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 $90 
copayment for Emergency Care.  
 
You have been asked to pay a $90 copayment for an emergency room visit. An emergency room visit falls 
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 $90 copayment for an 
emergency room visit on March 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Oxygen equipment (E0431, E1390) 
provided on September 22, 2021. 
 
You asked the Plan to waive the copayment for the oxygen equipment. You say that the services should be 
covered as you disagree with the charges, were not made aware of them, and they accumulated over time. 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 Durable Medical Equipment (DME) and related supplies.  
 
 
  You have been asked to pay a 20% coinsurance for the oxygen equipment (allowed is $136.32 x 20% = 
$27.26). Oxygen equipment falls within the Durable Medical Equipment (DME) and related supplies benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for Oxygen equipment (E0431, E1390) provided 
on September 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $290 copayment for an outpatient hospital facility visit on 
October 27, 2021. 
 
You asked the Plan to waive the $290 copayment for an outpatient hospital facility visit. You say that you 
should not be responsible for this copayment. The Plan denied your request. The Plan says you are responsible 
to pay a $290 copayment for each in-network outpatient hospital facility 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 $290 
copayment for Outpatient Hospital Services.  
 
You have been asked to pay a $290 copayment for an outpatient hospital facility visit. Outpatient hospital 
facility visits fall within the Outpatient Hospital 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 $290 copayment for an outpatient hospital facility visit on October 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CxBladder testing (0013M) provided on January 19, 2022. 
 
You asked the Plan to pay for CxBladder testing. You say that you disagree with this decision. The Plan denied 
your request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that CxBladder test code 0013M is not covered by 
Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of CxBladder testing have not been met. Therefore, we decided that the Plan does not have to pay for 
CxBladder testing (0013M) provided on January 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 1, 2022, 
to April 2, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you were vomiting for more than 24 
hours. You say that you went to urgent care initially. You also say that you were advised you should go to the 
emergency room due to your medical history. The Plan denied your request. The Plan says the admission was 
not medically reasonable or necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the provided documentation does not show that at the time of inpatient admission the 
admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. Therefore, the reviewer found that the inpatient admission was 
not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from April 1, 2022, to April 2, 2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance service, basic life support, non-emergency transport 
(A0428) and ground mileage (A0425) provided on December 15, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that the ambulance services were medically 
necessary. You say that the enrollee requires transportation to medical and dental appointments. You also say 
that the enrollee is not able to travel upright. The Plan denied your request. The Plan says that the criteria have 
not been met. 
 
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 file does not include any medical records to support the Plan's 
denial. Therefore, we decided that the Plan has to pay for the ambulance service, basic life support, non-
emergency transport (A0428) and ground mileage (A0425) provided on December 15, 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.