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

 
We decided that the Plan does not have to pay for self-administered drugs provided on January 30, 2023. 
 
You asked the Plan to pay for self-administered drugs. You say that the procedure should be covered under 
your insurance plan. The Plan denied your request. The Plan says self-administered drugs do not fall under 
Medicare Part B coverage. 
 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 pay for self-administered drugs provided 
on January 30, 2023.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for podiatry visit provided on January 24, 
2023. 
 
You asked the Plan to waive the copayment for podiatry visit. You say that you are requesting the second 
copayment to be removed because its not fair to pay for the other vist. 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 $45 
copayment for podiatry service. 
 
You have been asked to pay a $45 copayment for podiatry visit. This item/service falls within the podiatry 
service benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for podiatry visit provided on 
January 24, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the inpatient hospital stays, and the 
injections provided from November 25, 2022, to January 11, 2023. 
 
You asked the Plan to waive the cost share for the inpatient hospital stays and the injections. You say that the 
enrollee should not have been discharged the first time and should not have to pay for a two separate stays. 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 $300 copayment per admission, for each medically necessary inpatient stay. The enrollees contract 
with the Plan also clearly says enrollees must pay 20% coinsurance for Medicare Part B drugs. 
 
The enrollee has been asked to pay a $300 copayment for each inpatient hospital stay provided on November 
25, 2022, and December 10, 2022. You have been asked to pay a total of $600 ($300 copayment x 2 stays = 
$600). These items/services fall within the inpatient hospital care benefit category. The enrollee has also been 
asked to pay 20% coinsurance of the allowed amount for the injections. These items/services fall within the 
Medicare Part B prescription drugs benefit category.  
 
Date of service Code Allowed Amount 20% Coinsurance 
December 21, 2022 J9305 $2,435.09 $487.02 
December 21, 2022 J9305 $1,461.05 $292.21 
January 11, 2023 J9022 $9,889.79 $1,977.96 
January 11, 2023 J9305 $1,411.73 $282.35 
January 11, 2023 J9305 $847.03 $169.41 
January 11, 2023 Q5107 $2,586.39 $517.28 
January 11, 2023 Q5107 $226.30 $45.26 
January 11, 2023 Q5107 $96.99 $19.40 
 
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This 
cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we 
decided that the Plan does not have to waive the cost share for the inpatient hospital stays, and the injections 
provided from November 25, 2022, to January 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an in-network podiatry visit provided on 
February 2, 2023. 
 
You asked the Plan to waive the deductible for an in-network podiatry visit. You say that you only went in for 
a toenail trim and did not have any other assessments done. The $35 copayment you paid at the time of the visit 
should be all you owe. 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 $750 
deductible for podiatry and other applicable services.  
 
You have been asked to pay a $131.51 deductible for an in-network podiatry visit. This item/service falls 
within the podiatry 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 deductible for an in-
network podiatry visit provided on February 2, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-rays provided on January 01, 2023. 
 
You asked the Plan to pay for x-rays. You say that you are requesting the submitted documentation be 
reviewed. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for x-rays provided on 
January 01, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for echocardiography (ECG) provided on June 
29, 2022, to June 30, 2022. 
 
You asked the Plan to waive the copayment for echocardiography (ECG). You say that you disagree with the 
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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $135 
copayment for outpatient diagnostic tests/Medicarecovered radiological diagnostic services. 
 
You have been asked to pay a $135 copayment for echocardiography (ECG). This item/service falls within the 
outpatient diagnostic tests/Medicarecovered radiological diagnostic 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 echocardiography (ECG) provided on June 29, 2022, to June 30, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on December 29, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $165 
copayment for outpatient diagnostic tests/Medicarecovered non-radiological diagnostic services. 
 
You have been asked to pay a $165 copayment for an ultrasound. This item/service falls within the outpatient 
diagnostic tests/Medicarecovered non-radiological diagnostic 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 ultrasound provided on December 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiovascular stress test provided on October 26, 2022. 
 
You asked the Plan to pay for cardiovascular stress test. You say that this service is supported in the records. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for cardiovascular stress test 
provided on October 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 14, 2022. 
 
You asked the Plan to pay for an office visit. You say that this service was medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on November 14, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the cardiac rehabilitation visits provided 
from January 4, 2023, to January 31, 2023. 
 
You asked the Plan to waive the deductible for cardiac rehab visits. You say that the 2022 deductible should 
apply for the 2023 sessions. 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 a $600 deductible which applies to Your contract with the Plan. Your 
contract with the Plan also says that there is a $30 copayment once the deductible has been met. 
 
 You have been asked to pay $118.30 towards your deductible for each cardiac rehab visit provided on January 
4, 2022, January 12, 2022, January 18, 2022, January 25, 2022, and January 31, 2022. You have been asked to 
pay a total of $591.50 ($118.30 deductible x 5 visits = $591.50). The items or services you asked the Plan to 
waive the deductible for fall within the cardiac rehabilitation services benefit category. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $600 deductible which applies to cardiac 
rehabilitation services. This cost sharing is a contractual obligation that had not been met at the time cardiac 
rehab visits was received on January 4, 2023, to January 31, 2023. Therefore, we decided that the Plan does not 
have to waive the deductible for the cardiac rehabilitation visits provided from January 4, 2023, to January 31, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 18, 2022. 
 
You asked the Plan to pay for lab services. You say that this is supported in the records. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab services provided on 
August 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the physical, occupational, and speech 
therapies required are not able to be met at the current facility. The Plan denied your request. The Plan says an 
LTACH admission is not medically necessary, and the member's needs are being met at current level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
  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 the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services. The enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that they are not currently 
receiving but that would be available at the LTACH facility. The requested service cannot be recommended as 
the elements of the coverage rules are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network infusion treatment provided 
on December 7, 2022. 
 
You asked the Plan to waive the coinsurance for an in-network infusion treatment. You say that this is way too 
expensive. You cannot afford a coinsurance that high, and you were unaware that this amount had changed. 
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 20% 
coinsurance for Medicare Part B prescription drugs. The allowed amount of this drug is $1,627.22, resulting in 
a coinsurance amount of $325.44 ($1,627.22 x 20% = $325.44). You are being asked to pay $313.34 which is 
less than the 20% coinsurance. 
 You have been asked to pay a $313.34 coinsurance for an in-network infusion treatment. This item/service 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 coinsurance for an in-network infusion treatment provided on December 7, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on July 28, 2022. 
 
You asked the Plan to pay for physical therapy. You say that you are appealing this denial. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for physical therapy 
provided on July 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia provided on February 13, 2023. 
 You asked the Plan to pay for anesthesia. You say that the enrollee revoked hospice on February 12, 2023, 
which was before they were seen. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment. 
 
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 February 12, 2023. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for anesthesia provided 
on February 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on February 7, 2023. 
 
You asked the Plan to pay for telehealth services. The Plan denied your request. The Plan says out-of-network 
telehealth services are not payable. 
 
The Plan contract says Virtual care (also referred to as telehealth services, virtual check-ins or eVisits) are not 
covered out-of-network. 
 
We looked at the file and the Plans rules. The file shows that telehealth services are not covered out-of-
network.  Based on this information, we decided that the Plans rules for coverage of telehealth services have 
not been met. Therefore, we decided that the Plan does not have to pay for telehealth services provided on 
February 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home or residence visit provided on January 10, 2023. 
 
You asked the Plan to pay for a home or residence visit. You say that it is the responsibility of the facility to 
obtain authorization. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home or residence visit 
provided on January 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service July 28, 
2022. 
 
You asked the Plan to pay for procedure code 99223. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 99223 is bundled into 
payment for code 33249. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99223 
is a column II code to column I code 33249. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99223 billed for date of service July 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital claim for services provided on August 
22, 2022. 
 
You asked the Plan to pay for the outpatient hospital claim. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says procedure code 31800 is an inpatient only 
procedure code that was billed on an outpatient claim. 
 
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that 
CMS designates to be inpatient-only services. These services have an OPPS status indicator of C in the 
OPPS Addendum B and are listed together in Addendum E of each years OPPS/ASC final rule.  
 
The service at issue in this appeal was billed with CPT code 31800. This code is listed with a status indicator of 
C on Addendum B of the 2022 OPPS/ASC final rule. This means the service has been designated as inpatient only, and therefore must be billed as part of an inpatient admission. The file shows the services 
were incorrectly billed on an outpatient claim. Therefore, we decided that the Plan does not have to pay for the 
outpatient hospital claim for services provided on August 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home or residence visit provided on August 20, 2022. 
 
You asked the Plan to pay for a home or residence visit. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home or residence visit 
provided on August 20, 2022.