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

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on March 16, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on March 
16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the diagnostic agent piflufolastat provided 
on March 11, 2022. 
 
You asked the Plan to waive the cost share for the piflufolastat injection. You say that were told the normal 
copay for this service is $20. You say that because you were not told about this charge you are requesting it be 
dropped. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for medical supplies and chemical agents.  
 
You have been asked to pay a 20% coinsurance for the piflufolastat injection for a total of $917.79 ($4588.94 
the allowed amount x 20% coinsurance = $917.79). The piflufolastat injection 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 cost share for the diagnostic agent piflufolastat provided on March 11, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for chemotherapy administration provided on  
February 24, 2022. 
 
You asked the Plan to waive the coinsurance for chemotherapy administration. You say that you have not been 
charged for the chemotherapy infusion before. You say that you have only been charged the 20% coinsurance 
on Part B drug for years. The Plan denied your request. The Plan says that the coinsurance applied was correct. 
 
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 enrollees must pay a 20% coinsurance for Medicare Part B Prescription Drugs. 
The contract does not specify a coinsurance for administration of that drug. 
 
The Plan says you must pay a 20% coinsurance for chemotherapy administration, for a total of $26.75. Based 
on the Plan contract, however, you cannot be asked to pay for chemotherapy administration. Therefore, we 
decided that the Plan has to waive the coinsurance for chemotherapy administration (96413) provided on 
February 24, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (ECG) provided on 
April 18, 2022. 
 
You asked the Plan to waive the copayment for an ECG. You say that you believe you should only be charged 
a $5 specialist 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 $25 
copayment for diagnostic procedures and tests, including ultrasounds, at all locations of service.  
 
 
  You have been asked to pay $15.02 for an ECG, which is less than your $25 copayment. An ECG 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 electrocardiogram (ECG) provided on April 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 9, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this should be paid for. The 
Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intraosseous ablation of the basivertebral nerve (the 
Intracept procedure). 
 
You asked the Plan to pre-approve Intracept. You say that this procedure fills a treatment gap for patients that 
do not receive adequate relief from traditional conservative method and do not have instability to indicate that 
fusion is appropriate. The Plan denied your request. The Plan says the Intracept procedure is 
experimental/investigational. 
 
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 Intracept. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Intracept procedure is considered investigational at this time. There is insufficient evidence 
to demonstrate that this procedure is medically reasonable and neessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have 
to pre-approve intraosseous ablation of the basivertebral nerve (the Intracept procedure).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist office visits provided from 
February 8, 2022, to February 15, 2022. 
 
You asked the Plan to waive the copayments for the specialist visits. You say that you saw your PCP for these 
visits. 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 $45 
copayment for each specialist visit.  
 
The file shows that the Plan verified the provider is listed as a specialty provider. Therefore, you have been 
asked to pay a $45 copayment for each of the specialist visits, for a total of $90. The specialist visits fall 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. Therefore, we decided that the Plan does not have 
to waive the copayments for specialist office visits provided from February 8, 2022, to February 15, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for an eye appointment and a ranibizumab injection 
provided on January 7, 2022. 
 
You asked the Plan to waive the cost for an eye appointment and injection. You say that this cost is too high, 
and you should not have to pay it. The Plan denied your request. The Plan says the cost share 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 $35 
copayment for an eye visit and a 20% coinsurance for Part B drugs injections. The allowed amount of this item 
is $3,071.98 resulting in a coinsurance amount of $614.40 ($3,071.98 x 20% = $614.40) + a $35 copayment 
($614.40 + $35 = $649.40). 
 
You have been asked to pay a $649.40 cost share for Part B drugs injections and for an eye appointment. An 
eye appointment falls into the Vision Care benefit category, and an 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 cost for an eye appointment and a ranibizumab injection provided on 
January 7, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
March 2, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you are on a fixed 
income and cannot afford the copayment. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $317 
copayment for each one-way ambulance transport.  
 
You have been asked to pay a $317 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 March 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the magnetic resonance imaging (MRI) of 
the arm provided on March 24, 2022. 
 
You asked the Plan to waive the cost share for the MRI. You say that you were not informed that the provider 
was not in your plans network. 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 50% 
coinsurance for out-of-network advanced imaging services.  
 
You have been asked to pay a 50% coinsurance for out-of-network advanced imaging services for a total of 
$138.37 ($276.74 the allowed amount x 50% coinsurance = $138.37). The MRI falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the cost share for the magnetic resonance imaging (MRI) of the arm provided on March 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a specialist visit provided on January 12, 
2022. 
 
You asked the Plan to waive the deductible for a specialist visit. You say that the bill for this deductible came 
so late that you had already reached your deductible amount. The Plan denied your request. The Plan says the 
deductible that was applied was correct. 
 
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 $400 deductible which applies to Section 1.2: What is your plan 
deductible.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Section 1.2: 
What Is Your Plan Deductible. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $194.08 deductible which applies to Section 1.2: What is your plan deductible. This cost sharing is a 
contractual obligation that had not been met at the time a specialist visit was received on January 12, 2022. 
Therefore, we decided that the Plan does not have to waive the deductible for a specialist visit provided on 
January 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a specialist office visit provided on  
March 22, 2022. 
 
You asked the Plan to waive the deductible for a specialist office visit. You say that you were told this would 
be a $45 copayment. You say that you believe the additional charge of $93.14, for a total of $138.14, is 
incorrect. The Plan denied your request. The Plan says the deductible applied was correct. 
 
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 $1,000 deductible which applies to Medicare-covered physician 
specialist services provided out-of-network.  
 
You have been asked to pay a total of $138.14 towards your deductible. The item or service you asked the Plan 
to waive the deductible for falls within the Physician/Practitioner Services, Including Doctors Office Visits, 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$1,000 deductible which applies to Medicare-covered physician specialist services provided out-of-network. 
This cost sharing is a contractual obligation that had not been met at the time a specialist office visit was 
received on March 22, 2022. Therefore, we decided that the Plan does not have to waive the deductible for a 
specialist office visit provided on March 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the trastuzumab and fosaprepitant injections 
provided on September 16, 2021. 
 
You asked the Plan to waive the cost share for the Part B drugs. You say that you have cancer and social 
security is your only income and you cannot afford these bills. The Plan denied your request. The Plan says you 
have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Part B drugs.  
 
You have been asked to pay a 20% coinsurance for the Part B drugs for a total of $192.71 ($963.56 the allowed 
amount x 20% coinsurance = $192.71). 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 cost share for the trastuzumab and fosaprepitant injections 
provided on September 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on February 1, 
2022. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that you were only seen for a 
COVID-19 test. 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 $50 
copayment for urgently needed services provided at an urgent care center.  
 
You have been asked to pay a $50 copayment for the urgent care visit. The urgent care visit falls within the 
Urgently Needed 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 an urgent 
care visit provided on February 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for a procedure to place stents provided on January 
28, 2022. 
 
You asked the Plan to waive the cost for a procedure to place stents. You say that you have had this procedure 
before and were not charged these kinds of amounts. The Plan denied your request. The Plan says the cost 
share 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 $15 
copayment for outpatient hospital services and a 20% coinsurance for outpatient diagnostic tests. The allowed 
amount of this item is $11932.50 resulting in a coinsurance amount of $2,386.50 ($11932.50 x 20% = 
$2,386.50). $2,386.50 + $15 copayment = $2444.34. 
 
You have been asked to pay a total cost of $2444.34 for a procedure to place stents. A procedure to place stents 
falls within the Outpatient Diagnostic Tests and 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 cost for a procedure to place stents provided on January 28, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you want to make sure you have trips 
available to make it to your appointments for cancer treatment. The Plan denied your request. The Plan says 
your request for additional transportation benefits beyond 48 rides is not covered. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers up to 48 one-way rides per year. 
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. The record shows that as of 
August 3, 2022, you had 35 of 48 rides left. Additional rides beyond the 48 trips allowed are not a covered 
benefit. Therefore, we decided that the Plan does not have to pre-approve additional transportation.
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 the IRF care is medically necessary. The Plan denied 
your request. The Plan says authorization denied because the IRF care is not medically necessary, and the 
enrollee's needs can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 the enrollee's medical problems are stable, and there are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services 
 
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 pay for the subsequent hospital care (99233) provided from January 
24, 2022, to January 29, 2022. 
 
You asked the Plan to pay for the hospital care. You say that the enrollee was no longer enrolled in hospice on 
the dates of service in this case. 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on January 8, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent 
hospital care (99233) provided from January 24, 2022, to January 29, 2022.