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

 
We decided that the Plan does not have to waive the copayment lab services you received on April 16, 2021. 
 
You asked the Plan to waive the copayment the lab services. You say that these lab services were part of an 
office visit you had on that date. The Plan denied your request. The Plan says you were charged this copayment 
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). Your contract with the Plan clearly says that you must pay a $5 
copayment for lab services.  
 
You have been asked to pay a $5 copayment for the lab services. Your Evidence of Coverage clearly states that 
if you receive services beyond the office visit with your physician, separate cost sharing will apply. 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 lab services you received on April 16, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the X-ray transportation services (R0070) provided May 13, 
2021. 
 
You asked the Plan to pay for the X-ray transportation services. You say that you would like this claim 
reprocessed based on medical necessity. The Plan denied your request. The Plan says the claim has been billed 
with an inappropriate place of service 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. 
 
In this case, the CPT Code Manual definition of code R0070 is transportation of portable x-ray equipment and 
personnel to home or nursing home, per trip to facility or location, one patient seen. 
 
We looked at the file and Medicare rules. The records show that the claim for the services in dispute was billed 
with a POS code of 31. The record indicates that the member was not in a Part A covered SNF stay on the 
billed date of service. There is a more appropriate POS code for the billed services. Based on this information, 
we decided that Medicare rules for coverage of the X-ray transportation services have not been met. Therefore, 
we decided that the Plan does not have to pay for the X-ray transportation services (R0070) provided May 13, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic injection for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says self-administered drugs are not a covered benefit. 
 
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 pre-approve Ozempic injection for the 
enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services you received 
from June 19, 2021, to June 24, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were arrested 
and sent to the hospital involuntarily, so you should not have to pay this copayment. The Plan denied your 
request. The Plan says you were charged this copayment 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). Your contract with the Plan clearly says that you must pay a $320 
copayment per day for days 1-5 for inpatient hospital services.  
 
You have been asked to pay a $320 copayment per day for days 1-5 for the inpatient hospital services. This 
copayment applies regardless of the reason for your inpatient stay. 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 inpatient hospital services you received from June 19, 2021, to June 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Keytruda injections you received on 
April 5, 2021. 
 
You asked the Plan to waive the coinsurance for the Keytruda injections. You did not provide an argument in 
your appeal request for date of service April 5, 2021. The Plan denied your request. The Plan says you were 
charged this coinsurance 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). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B drugs.  
 
You have been asked to pay 20% coinsurance for the Keytruda injections. The Keytruda injections fall within 
the Medicare Part B 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 
Keytruda injections you received on April 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services coded 30140, 31237, 31259, 31267, 
31276, and 61782 provided from January 8, 2021, through January 13, 2021. 
 
You asked the Plan to pay for the medical services as coded. You say that you would like these claims 
reprocessed based on the medical documentation provided. The Plan denied your request. The Plan says these 
codes have denied correctly according to Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2. Medicare rules say that providers must report 
services correctly. Providers must report services with the appropriate CPT code. 
 
In this case, the MUE for CPT codes 30140, 31237, 31259, 31267, and 31276 is 1. The MAI value for this code 
is 2. You billed 2 units of these codes, exceeding the MUE. Based on this information, we decided that 
Medicare rules for coverage of the medical services as coded have not been met. Furthermore, we have 
confirmed that code 61782 is an add-on code and has not been billed with an appropriate primary procedure 
code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the 
Plan does not have to pay for the medical services coded 30140, 31237, 31259, 31267, 31276, and 61782 
provided from January 8, 2021, through January 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services (97139, 97750) and drug services 
(J3490, J3490-59, 96372) associated with Sanexas therapy provided on April 5, 2021. 
 You asked the Plan to pay for the Sanexas therapy. You say that you would like these claims reprocessed for 
medical necessity. The Plan denied your request. The Plan says these services are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare pays for outpatient physical therapy 
services only if they are furnished by, or under the direct supervision of a physical therapist in private practice; 
or by, or incident to the services of a nurse practitioner (NP) or physician assistant (PA) only when that 
practitioner may perform services under state law. Medicare rules say that compounded drugs shall be 
submitted using a compounded drug, not otherwise classified code. 
 
We looked at the file and Medicare rules. Review of the file and publicly available records, we find that the  
physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide  
physical therapy in the State of Oklahoma. The multiple drug codes reported on this claim refer to a pre-filled  
compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not  
otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made.  
Because the drugs are not paid as billed, the drug administration codes also cannot be paid. Therefore, we 
decided that the Plan does not have to pay for the therapy services (97139, 97750) and drug services (J3490, 
J3490-59, 96372) associated with Sanexas therapy provided on April 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Hyalgan injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says the rules in the guidelines say that at least six months must have elapsed since the initial 
or prior treatment cycle. 
 
The Plan must follow Medicare rules. The rules say that at least six months must have elapsed since the last 
intraarticular knee injections of hyaluronan before repeat treatments can be approved. 
 
Injections were last received in August of 2021. Six months must pass until the next injection. Based on this 
information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Hyalgan injection for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation hospital stay 
you had from March 3, 2021, to March 13, 2021. 
 
You asked the Plan to waive the copayment for the inpatient rehabilitation hospital services. You say that the 
case worker failed to inform you that this stay would have a copayment.  You stated that you simply moved 
from the hospital portion of the facility to the rehab portion of the facility, so you should not have to pay 
separate copayments. You stated that if you had known, you could have been transferred to a facility that didn't 
have a copayment. The Plan denied your request. The Plan says you were charged this copayment 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). Your contract with the Plan clearly says that you must pay a $490 
copayment per day for days 1-3, and a $0 copayment for each additional day for inpatient hospital services.  
 
You have been asked to pay a $490 copayment per day for days 1-3 for the inpatient rehabilitation hospital 
services. According to your Evidence of Coverage, this cost sharing applies each time you are admitted to a 
hospital.  It's considered a new admission if you are transferred from a hospital to a separate type of facility 
(such as an acute inpatient rehabilitation hospital).  That is exactly what happened here- you were transferred 
from an acute care hospital to an acute inpatient rehabilitation facility.  While it is true that under your contract, 
skilled nursing facility care is $0, you were not transferred to a skilled nursing facility.  You were transferred to 
an inpatient rehabilitation hospital, which requires this copayment. The Plan has met its burden by disclosing 
this to you in your contract document. 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 inpatient 
rehabilitation hospital stay you had from March 3, 2021, to March 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prodigy no coding test strips 30/30. 
 
You asked the Plan to pre-approve Prodigy no coding test strips 30/30. You say that the enrollee is using a non-
preferred meter and test strips adapted to a dexterity impairment. The Plan denied your request. The Plan says 
the non-preferred test strips are not medically necessary for the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may limit coverage of DME to preferred 
brands and manufacturers as long as the enrollee retains access to all medically necessary items. Medicare rules 
also say that information must be submitted by providers to confirm that Medicare coverage criteria have been 
met.  
 
We looked at the file and Medicare rules. The case file did not include any medical records. The Plan showed evidence of having made reasonable attempts to obtain medical records. Without this information there is no 
evidence that the non-preferred brand of test strips are medically necessary. Based on this information, we 
decided that Medicare rules for coverage of Prodigy no coding test strips 30/30 have not been met. Therefore, 
we decided that the Plan does not have to pre-approve Prodigy no coding test strips 30/30.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional expenses occurred during a public health emergency (99072) 
on January 15, 2021. 
 
You asked the Plan to pay for the additional expenses. You say that this procedure code was correctly billed and should 
be paid. The Plan denied your request. The Plan says this code is not eligible for separate payment. 
 
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 99072 is not supported in the medical record. Specifically, per the National Physician Fee 
Schedule, this code has a status of "B" and payment is always bundled with another service. Based on this information, 
we decided that Medicare rules for coverage of the additional expenses have not been met. Therefore, we decided that the 
Plan does not have to pay for additional expenses occurred during a public health emergency (99072) on January 15, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the companion care services coded S5136 
 
You asked the Plan to pay for the companion care services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services received are not a covered benefit. 
 
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 S5136 is Companion care, adult; per diem. 
 
We find that CPT code S5136 is not supported in the medical record. Specifically, this code has a status code 
of "I". A status code of I means that these services are not valid for Medicare purposes. Medicare uses another 
code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules 
for coverage of the companion care services have not been met. Therefore, we decided that the Plan does not 
have to pay for the companion care services coded S5136
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services you 
received from March 11, 2021, to March 18, 2021. 
 
You asked the Plan to waive the copayment for the SNF services. You say that you asked one of the staff at the 
SNF how long you could stay without having to pay.  You said that they told you until March 19, 2021, and 
that's when you left the facility. The Plan denied your request. The Plan says you were charged this copayment 
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). Your contract with the Plan clearly says that you must pay a $0 
copayment for days 1-20, and a $160 copayment per day for days 21-100 for skilled nursing facility services.  
 Records show that you were in the SNF from February 19, 2021, to March 19, 2021, for a total of 28 days.  
You were not charged a copayment for the first 20 days.  You were charged a $160 copayment per day from 
March 11, 2021, through March 18, 2021, for a total of 8 days, equaling $1280.  You were not charged a 
copayment on the day of discharge (March 19, 2021.) The Plan clearly discloses in their contract that you have 
to pay for SNF services after 20 days. You were in the SNF for more than 20 days, so this copayment applies. 
Furthermore, the SNF where you stayed is not a network facility.  If they gave you incorrect benefit 
information, the Plan cannot be held responsible for that when your Evidence of Coverage clearly discloses 
your cost sharing obligations. 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 skilled nursing facility 
(SNF) services you received from March 11, 2021, to March 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services you received on March 
28, 2021. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you cannot afford this 
copayment. The Plan denied your request. The Plan says you were charged this copayment 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). Your contract with the Plan clearly says that you must pay a $195 
copayment per one-way trip for ambulance services.  
 
You have been asked to pay a $195 copayment for the ambulance services. 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 services you received on March 28, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on 
June 23, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you had a bad experience, so you 
should not have to pay this bill. The Plan denied your request. The Plan says you were charged this copayment 
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). Your contract with the Plan clearly says that you must pay a $90 
copayment for emergency room services.  
 
You have been asked to pay a $90 copayment for the ER visit. This copayment applies regardless of your 
satisfaction with the services received. 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 
emergency room (ER) visit you had on June 23, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on 
May 8, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you would like to appeal this charge 
and you can provide documentation explaining why. The Plan denied your request. The Plan says you were 
charged this copayment 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). Your contract with the Plan clearly says that you must pay a $90 
copayment for emergency room services.  
 
You have been asked to pay a $90 copayment for the ER visit. This copayment applies each time you visit the 
ER, regardless of the reason and regardless of your satisfaction with the services. 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 emergency room (ER) visit you had on May 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services you received on June 
15, 2021. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you don't believe you 
should have to pay this copayment. You stated that the ambulance had no lights on during the transport and you 
didn't receive medication during the ride.  You said it was just transportation between facilities. The Plan 
denied your request. The Plan says you were charged this copayment 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). Your contract with the Plan clearly says that you must pay a $125 
copayment for ambulance services.  
 
You have been asked to pay a $125 copayment for the ambulance services. This copayment applies regardless of the reason for the transport and regardless of what on-board services are used. 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 services you received on June 15, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the pelvic ultrasound you had on April 10, 2021. 
 
You asked the Plan to waive the deductible for the pelvic ultrasound. You say that you didn't know that you had to pay a 
deductible. The Plan denied your request. The Plan says you were charged this deductible 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 a $500 deductible which applies to outpatient diagnostic services.  
 
The ultrasound falls within the benefit category of outpatient diagnostic services. The Plan has followed Medicare rules 
by clearly disclosing in the contract that there is a $500 deductible which applies to outpatient diagnostic services. This 
cost sharing is a contractual obligation that had not been met at the time the pelvic ultrasound was received on April 10, 
2021. Therefore, we decided that the Plan does not have to waive the deductible for the pelvic ultrasound you had on 
April 10, 2021.