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

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service December 7, 
2021. 
 
You asked the Plan to pay for procedure code 99100. You say that this should be paid for. The Plan denied 
your request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service December 7, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on May 27, 
2022. 
 
You asked the Plan to waive the copayment for ambulance. You say that you were only in ambulance for about 
5 minutes. The Plan denied your request. The Plan says this cost sharing was charged 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 $300 
copayment for per day for Medicare-covered ambulance round-trip services.  
 
You have been asked to pay $300 copayment for ambulance. This item/service falls within the per day for 
Medicare-covered ambulance round-trip 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 services provided on May 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a bladder tube change performed on the 
enrollee on March 30, 2022. 
 
You asked the Plan to waive the copayment for the bladder tube change. You say that you feel the procedure is 
not surgical. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $250 copayment for outpatient surgery, including services provided at hospital outpatient facilities 
and ambulatory surgical centers.  The enrollee was asked to pay a $250 copayment for the bladder tube change. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
benefit category. This means that the enrollee was asked to pay the correct amount based on the contract with 
the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for a bladder tube change performed 
on the enrollee on March 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on May 04, 2022, to May 11, 
2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged 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 $40 
copayment for each specialist office visit for Medicare-covered services. Covered services include 
consultation, diagnosis, and treatment by a specialist. There were 2 dates of service. 2 x $40 = $80. Therefore, 
reuslts in the total cost sharing amount of $80.  
 
 
 
 
 You have been asked to pay a $40 copayment for each office visit. This item/service falls within the 
Physician/practitioner services, including doctor's office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for office visit on May 04, 2022, to May 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service December 
23, 2021. 
 
You asked the Plan to pay for procedure code 99100. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99100 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service December 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external infusion pump. 
 
You asked the Plan to pre-approve an external infusion pump. You say that the requested external infusion 
pump is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria 
for the requested external infusion pump. 
 
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 an external infusion pump. Our 
reviewer says that the enrollee does not meet criteria for the requested external infusion pump. Our physician 
reviewer found the plan requires that the enrollee have pancreatic antibodies suggesting type 1 diabetes 
mellitus OR that the enrollee has a low c-peptide suggesting insulinopenia. Based on the documentation 
provided, there is no c-peptide level; the level would have to be less than 110% of the lower limit of normal of 
the assay. This does not mean that the pump would not help this enrollee; it does mean that insulin pump 
coverage criteria are not met for this enrollee at this time. If there is a c-peptide level with simultaneous 
glucose level available it should be submitted and the case re-reviewed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an external infusion pump have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an external infusion pump.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance ride provided on May 08, 
2022. 
 
You asked the Plan to waive the copayment for an ambulance ride. You say that this is an outrageous charge 
for an ambulance ride. The Plan denied your request. The Plan says this cost sharing was charged 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 $225 
copayment for ambulance services. 
 
You have been asked to pay a $225 copayment for an ambulance ride. This item/service 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 an ambulance ride 
provided on May 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a chiropractic visit provided on June 03, 
2022. 
 
You asked the Plan to waive the copayment for a chiropractic visit. You say that you thought you had 12 visits 
without copayments. The Plan denied your request. The Plan says this cost sharing was charged 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 $15 
copayment for chiropractic services. 
 
You have been asked to pay a $15 copayment for a chiropractic visit. This item/service falls within the 
chiropractic 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 a chiropractic visit 
provided on June 03, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care on March 08, 2022, to May 05, 
2022. 
 
You asked the Plan to waive the copayment for urgent care. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged 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 $50 
copayment for each Medicare-covered urgent care facility visit. This copayment is not waived if you are 
admitted as an inpatient to the hospital within 24 hours for the same condition. Urgently needed services are 
provided to treat a non-emergency, unforeseen medical illness, injury, or condition that requires immediate 
medical care. Urgently needed services may be furnished by network providers or by out-of-network providers 
when network providers are temporarily unavailable or inaccessible. There were 2 dates of service. 2 x $50 = 
$100. Therefore, resutls in the total cost sharing amount of $100. You have been asked to pay a $50 copayment for each urgent care. This item/service 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 urgent care on March 08, 
2022, to May 05, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and copayment for an outpatient procedure 
performed on May 10, 2022. 
 
You asked the Plan to waive the deductible and copayment for the outpatient procedure. You say that you 
should only owe the $275 copayment. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $750 deductible which applies to surgery services at an outpatient 
hospital.  
 
The item or service you asked the Plan to waive the deductible and copayment for falls within the surgery 
services at an outpatient hospital benefit category. The Plan has followed Medicare rules by clearly disclosing 
in the contract that there is $750 deductible which applies to surgery services at an outpatient hospital. This 
cost sharing is a contractual obligation that had not been met at the time the outpatient procedure was received 
on May 10, 2022.   
The file shows that at the time of service, you had $295.16 remaining to meet your deductible. Once this was 
met, the $275 copayment is applied to the remainder of the cost. Therefore, we decided that the Plan does not 
have to waive the deductible and copayment for an outpatient procedure performed on May 10, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ER visit provided on July 26, 2022. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you believe nothing should be paid to 
the provider due to improper care and not receiving all discharge paperwork. The Plan denied your request. The 
Plan says this cost sharing was charged 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 each emergency care visit.  
 
You have been asked to pay a $90 copayment for an ER visit. This item/service 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 copayment for an ER visit provided on July 26, 
2022.  
 Your complaint about receiving improper care and not receiving all records is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laryngoscopy provided on June 02, 
2022. 
 
You asked the Plan to waive the copayment for the laryngoscopy. You say that the claim was filed under 
hospital facility in error. The Plan denied your request. The Plan says this cost sharing was charged 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 $375 
copayment for surgery services at an outpatient hospital. 
 
You have been asked to pay a $375 copayment for the laryngoscopy. This item/service falls within the surgery 
services at an outpatient hospital 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 
the laryngoscopy provided on June 02, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for outpatient hospital services, and laboratory 
services provided on June 16, 2022. 
 
You asked the Plan to reduce the copayment for outpatient hospital services and laboratory services. You say 
that you feel the copayment charge of $32.54 is incorrect and the amount should be $5.00. The Plan denied 
your request. The Plan says this cost sharing was charged 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 Medicare-covered outpatient lab services and a $400 copayment for Medicare-covered 
outpatient hospital services.  
 
 
  You have been asked to pay a total of $32.54 for outpatient hospital services and laboratory services. The total 
includes a $5 copayment for laboratory services and $27.54, which is less than the standard $400 copayment, 
for outpatient hospital services. Laboratory services fall within the Outpatient Diagnostic Tests and Therapeutic 
Services and Supplies benefit category. Outpatient hospital services 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 reduce the copayment for outpatient hospital services, and 
laboratory services provided on June 16, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on July 
07, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you needed to be 
transferred to another facility for a procedure and you were not expecting an ambulance bill. The Plan denied 
your request. The Plan says this cost sharing was charged 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 $250 
copayment for ambulance services. 
 
You have been asked to pay a $250 copayment for the ambulance services. This item/service 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 the ambulance 
services provided on July 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for telehealth visit provided on May 31, 2022. 
 
You asked the Plan to waive the copayment for telehealth visit. You say that this should be covered because 
your heart problem was due to COVID-19. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $40 
copayment for telehealth specialist visit. 
 
You have been asked to pay a $40 copayment for telehealth visit. This item/service falls within the telehealth 
specialist visit 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 telehealth visit provided 
on May 31, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency services provided on June 04, 
2022. 
 
You asked the Plan to waive the copayment for emergency services. You say that you should not be 
responsible to pay this. The Plan denied your request. The Plan says this cost sharing was charged 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 $120 
copayment for emergency services. 
 
You have been asked to pay a $120 copayment for emergency services. This item/service falls within the 
emergency 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 emergency services 
provided on June 04, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for echocardiology provided on July 09, 2021. 
 
You asked the Plan to waive the coinsurance for echocardiology. You say that you werent aware that the 
provider was out of network. The Plan denied your request. The Plan says this cost sharing was charged 
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 50% 
coinsurance for out of network Medicare-covered outpatient diagnostic radiology services. 
 
You have been asked to pay 50% coinsurance for echocardiology. This item/service falls within the out of 
network Medicare-covered outpatient diagnostic radiology 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 coinsurance for echocardiology provided on July 09, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the chiropractic manipulative treatment (98941) rendered by the out-of-
network (OON) provider on June 13, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the service was rendered by an out-of-
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that as a member of the Plan, you can receive your care from either a network provider or an out-of-
network provider.  
 
The provider in this case is not a network provider with the Plan. However, the Plan contract states that as a 
member of the Plan, you may receive your care from an in-network or out-of-network provider. Additionally, 
you do not need a referral or prior authorization when you get your care from out-of-network providers. 
Therefore, we decided that the Plan has to pay for the chiropractic manipulative treatment (98941) rendered by 
the out-of-network (OON) provider on June 13, 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.