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

 
We decided that the Plan does not have to pay for lab services (85060) provided December 14, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says coverage rules have not been met. 
 
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 85060 is not supported in the medical record. Specifically the code billed has a 
Professional Component / Technical Component of 8 and was billed for an outpatient service. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (85060) provided December 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (85060) provided December 14, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim was billed with an invalid place of service. 
 
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 85060 is not supported in the medical record. Specifically, the code billed has a 
Professional Component / Technical Component of 8 and was billed for an outpatient service. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (85060) provided December 14, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from May 
23 to June 21, 2021. 
 
You asked the Plan to pay for home health services. You say that you have submitted a RAP. The Plan denied 
your request. The Plan says rules for payment have not been met because no RAP has been submitted for the 
dates of service at issue. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, a RAP has 
not been submitted for the dates of service at issue. Therefore, we decided that the Plan does not have to pay 
for the home health services provided to the enrollee from May 23 to June 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit provided on February 16, 
2022. 
 
You asked the Plan to waive the deductible for an office visit. You say that this should be covered since you 
were told you needed this visit to go over lab results. The Plan denied your request. The Plan says the 
deductible applied is 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 $100 deductible which applies to office visits. 
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
Physician/Practitioner Services, Including Doctors Office Visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $100 deductible which applies to office visits. This cost sharing 
is a contractual obligation that had not been met at the time an office visit was received on February 16, 2022. 
Therefore, we decided that the Plan does not have to waive the deductible for an office visit provided on 
February 16, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
December 23, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you needed 
emergency transportation from the nursing home to the hospital. 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 $200 
copayment per day for ground ambulance transportation.  
 
You have been asked to pay a $200 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 December 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for CPAP supplies provided from December 
29, 2021, to February 28, 2022. 
 
You asked the Plan to waive the coinsurance for CPAP supplies. You say that you believe you shouldn't have 
to pay for the replacement CPAP. 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 Medicare covered durable medical equipment.  
 
 
 
 You have been asked to pay $66.96 which is 20% of the allowed amount for CPAP supplies. The allowed 
amount is $334.86 (20% x $334.86= $66.96).  CPAP supplies 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 coinsurance for CPAP 
supplies provided from December 29, 2021, to February 28, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on 
November 12, 2021. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you believe this charge 
should be covered. 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 $250 
copayment for each one-way Medicare covered ground trip.  
 
You have been asked to pay $250 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 November 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a leg scooter (E0118) and sales tax (S9999) provided 
December 13, 2021. 
 
You asked the Plan to pay for the leg scooter and sales tax.. You say that this item was medically necessary. 
The Plan denied your request. The Plan says the scooter is not covered under Medicare rules. No payment is 
made for sales taxes. 
 
The Plan must follow Medicare rules. Medicare rules say that a crutch substitute, lower leg platform (E0118) is 
not a covered item. Medicare rules also state that contractors do not make any additional payment for sales 
taxes. 
 
We looked at the file and Medicare rules. Neither the leg scooter or sales tax are covered under Medicare. 
Based on this information, we decided that Medicare rules for coverage of the leg scooter and sales tax. have 
not been met. Therefore, we decided that the Plan does not have to pay for a leg scooter (E0118) and sales tax 
(S9999) provided December 13, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive your cost share responsibility for an ultrasound performed on 
July 22, 2021. 
 
You asked the Plan to review your cost share responsibility for an ultrasound performed on July 22, 2021. You 
say that you should only pay a $40 copayment for the ultrasound performed on July 22, 2021. The Plan denied 
your request. The Plan says you are responsible to pay $239.28 because at the time this claim was processed, 
your deductible had not been met. 
 
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 $500 deductible which applies to Outpatient Diagnostic Tests And 
Therapeutic Services And Supplies.  
 
The item or service you asked the Plan to review your cost share responsibility falls within the benefit category 
Outpatient Diagnostic Tests And Therapeutic Services And Supplies.  
 The Plan has followed Medicare rules by clearly disclosing in the contract that there is $500 deductible which 
applies to Outpatient Diagnostic Tests And Therapeutic Services And Supplies. This cost sharing is a 
contractual obligation that had not been met at the time an ultrasound was received on July 22, 2021. 
Therefore, we decided that the Plan does not have to review your cost share responsibility for an ultrasound 
performed on July 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for outpatient eye surgery provided on 
January 11, 2022. 
 
You asked the Plan to reduce the copayment for eye surgery. You say that you were originally told it would be 
a $150 copayment, so you feel that price should be honored. 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 $220 
copayment for each Medicare-covered ambulatory surgical center visit. 
 
You have been asked to pay $220 copayment for eye surgery. Eye surgery falls within the Outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers 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 eye surgery provided on January 11, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for emergency services provided to the enrollee on October 30, 2021. 
 
You asked the Plan to pay for the services. You say that you do not show another visit for this date of service. 
The Plan denied your request. The Plan says that they were previously billed by and paid another provider for 
this service. 
 
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. The plan has not provided any evidence in the case of paying for the service with 
another provider. This would be needed to substantiate their denial. Therefore, we decided that the Plan has to 
pay for emergency services provided to the enrollee on October 30, 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management services (99239) 
provided to the enrolle on May 21, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the billed service cannot be verified without a documented duration time of 31 minutes or more. 
 
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 99239 is "Hospital discharge day management; more than 
30 minutes." 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the records do not document 
a duration time of 31 minutes or more in this case. Based on this information, we decided that Medicare rules 
for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for 
hospital discharge day management services (99239) provided to the enrolle on May 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for radiation therapy treatment provided from 
September 18, 2019, to September 30, 2019. 
 
You asked the Plan to waive the copayments for the radiation therapy. You say that the bill should have been 
included in the first treatment plan, and not months later. 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 $25 
copayment per day, per provider, for radiation therapy services.  
 
You have been asked to pay a $25 copayment for each of the 5 radiation therapy visits provided from 
September 18, 2019, to September 30, 2019, for a total of $125. The radiation therapy 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 copayments for radiation therapy treatment provided from September 18, 2019, to September 30, 
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
February 9, 2022. We also decided that the Plan does not have to waive the coinsurance for ferric 
carboxymaltose injections provided on February 9, 2022, and February 16, 2022. 
 
You asked the Plan to waive the copayment and coinsurance for the office visit and injections. You say that the 
provider did not inform you of the coinsurance at the times of service. The Plan denied your request. The Plan 
says the correct copayment and coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for each specialist visit. 
 
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for Part B drugs. 
 
You have been asked to pay a $35 copayment for the office visit. The office visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. You have also been asked to 
pay $168 for each injection, which is 20% of the allowed amount ($840 allowed amount x 20% coinsurance = 
$168). The injections fall within the Medicare Part B Prescription Drugs benefit category. The total for all 
services is $371. 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 specialist office visit provided 
on February 9, 2022. We also decided that the Plan does not have to waive the coinsurance for ferric 
carboxymaltose injections provided on February 9, 2022, and February 16, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
January 4, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you feel the charged 
amount is outrageous. 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 $270 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $270 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 January 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
 
We decided that the Plan does not have to waive the copayment for outpatient procedure provided on January 
4, 2022. 
 
You asked the Plan to waive the copayment for outpatient procedure. You say that you were told it would be a 
$35 copayment so that's all you should have to pay. 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 $325 
copayment for surgical services performed at an outpatient hospital facility.  
 
 
 
 You have been asked to pay $325 copayment for an outpatient procedure. Outpatient procedures fall within the 
Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 outpatient procedure provided on 
January 4, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 
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 a maximum of 20 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 sensor. 
 
You asked the Plan to pre-approve a Dexcom G6 sensor. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Dexcom G6 sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Dexcom G6 sensor.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on September 22, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the laboratory services by a contract provider. The file does not show that the 
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on September 22, 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.