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

 
We decided that the Plan does not have to pay for procedure codes A0426 and A0425 for date of service 
November 30, 2022.  
You asked the Plan to pay for procedure codes A0426 and A0425. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says non-physician services provided to inpatients which must 
be furnished directly by the hospital or billed through the hospital. 
 
The Plan must follow Medicare rules. Medicare rules say that services provided to inpatients must be furnished 
directly by the hospital or billed through the hospital. 
 
We looked at the file and Medicare rules. The services billed should be billed within the inpatient services. 
Based on this information, we decided that Medicare rules for coverage of procedure codes A0426 and A0425 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes A0426 and 
A0425 for date of service November 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient services on January 20, 2023, to 
February 13, 2023.  
 
You asked the Plan to waive the copayment for outpatient services. 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 $275 
copayment for Medicare-covered outpatient hospital observation services. There were three dates of service. 3 
x $275 = $825. Therefore, results in the total cost sharing amount of $825. 
 
 
 You have been asked to pay a $275 copayment for each outpatient service. This item/service falls within the 
outpatient hospital observation 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 services on January 20, 2023, to February 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the end-stage renal disease (ESRD) services provided on 
December 1, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the end-stage renal disease (ESRD) services. You say that these services were 
medically necessary. The Plan denied your request. The Plan says enrollees must receive their care from a 
network provider.  
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
items/services at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the end-stage renal disease (ESRD) services 
provided on December 1, 2022, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit coded 99284 and related 
services coded 87804, 87811, 85025, 80048, 71046, and 36415 for date of service September 3, 2022. 
 
You asked the Plan to pay for the emergency department visit and related services. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the emergency department visit coded 
99284 and related services coded 87804, 87811, 85025, 80048, 71046, and 36415 for date of service September 
3, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services (G0156). 
 
You asked the Plan to pre-approve home health services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be covered.  
 
The file does not show that you are homebound. Therefore, we decided that the Plan does not have to pre-
approve home health aide services (G0156).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient services on January 27, 2023. 
 
You asked the Plan to waive the copayment for outpatient services. You say that you were told that you would 
only have a $35 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 $275 
copayment for surgery services at outpatient hospital. Covered services include but are not limited to services 
in an emergency department or outpatient clinic, such as observation services or outpatient surgery. The 
provider billed in the amount of $358.51 and that allowed amount is $248.19. This is less than the copayment 
amount. Therefore, results in the total cost sharing amount of $248.19. 
 You have been asked to pay a $248.19 copayment, which is less than the copayment for outpatient services. 
This item/service falls 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 waive the copayment for outpatient services on January 27, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study to be provided by an out-of-network OON 
provider.  
 
You asked the Plan to pre-approve a sleep study. You say that you need this study because you cannot sleep. 
The Plan denied your request. The Plan says this service can be provided in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a sleep study to be provided by an out-of-network OON provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service November 
24, 2022.  
 
You asked the Plan to pay for procedure code 99285. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that if more than one evaluation and management 
(face-to-face) service is provided on the same day to the same patient by the same physician or more than one 
physician in the same specialty in the same group, only one evaluation and management service may be 
reported. 
 
We looked at the file and Medicare rules. The E/M service in question was provided on the same day as E/M service (99285-CS-GC) provided by a different provider in the same group. This means that only one E/M 
service is payable. As code 99285-CS-GC has already been processed and paid by the Plan, code 99285 is not 
payable in this case. Therefore, we decided that the Plan does not have to pay for procedure code 99285 billed 
for date of service November 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99458 billed for date of service February 28, 
2023.  
 
You asked the Plan to pay for procedure code 99458. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 99458 is 3. The MAI value for this code is 3. You billed 4 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99458 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99458 billed for date of service February 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections on March 08, 2023.  
 
You asked the Plan to waive the coinsurance for injections. You say that you cannot afford the coinsurance and 
would like to waive cost share. 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 Part B drugs, including chemotherapy drugs. These drugs are covered under Part B of Original 
Medicare. Members of our plan receive coverage for these drugs through our plan. Covered drugs include 
drugs that usually arent self-administered by the patient and are injected or infused while you are getting 
physician, hospital outpatient, or ambulatory surgical center services. The provider billed in the amount of 
$2,400 and the allowed amount is $1,350 for the services. $1,350.60 x 20% = $270.12. Therefore, results in the 
total cost sharing amount of $270.12. 
 
You have been asked to pay a 20% coinsurance for injections. 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 injections on March 
08, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network inpatient stay provided from 
January 3, 2023, to January 9, 2023. 
 
You asked the Plan to waive the copayment for an in-network inpatient stay . You say that you do not 
understand why you are being charged this large amount?  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 $370 
copayment per day for days 1-5 for inpatient hospital care.  
 
You were in the hospital for 3 days, resulting in a $1,110 total copayment ($370 x 3 = $1,110). 
 You have been asked to pay a $1,110 copayment for an in-network inpatient stay. This item/service falls within 
the inpatient hospital 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 in-
network inpatient stay provided from January 3, 2023, to January 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mobility scooter (K0801) and sales tax (S9999) 
purchased on July 20, 2022 from a non-certified provider. 
 
You asked the Plan to pay for the mobility scooter and sales tax. You say that you feel that the Plan's denial is 
unwarranted on the grounds that is not from a currently Medicare approved supplier when the supply chain at 
three different Medicare approved sources was unable to supply the device and had at best an extended 
estimated time for potential deliveries. You also say that the product you purchased is identical to one that 
would have been supplied by the initial provider, as there is no difference in the device model or the 
manufacturer. The Plan denied your request. The Plan says it was confirmed that Amazon.com is not included 
in Medicares Supplier Directory as a certified durable medical equipment provider and there were providers 
available for you to have received services. 
 
The Plan must follow Medicare rules. Medicare rules say that to receive payment for Medicare-covered items 
or services from either Medicare or a Medicare beneficiary, a provider or supplier must be enrolled in the 
Medicare program. The rules also say that Medicare does not make separate payment for sales tax.  
We looked at the file and Medicare rules. Specifically, the provider you purchased this scooter from is not 
enrolled in Medicare, and therefore, is not eligible for payment. Based on this information, we decided that 
Medicare rules for coverage of the mobility scooter and sales tax have not been met. Therefore, we decided that 
the Plan does not have to pay for the mobility scooter (K0801) and sales tax (S9999) purchased on July 20, 
2022 from a non-certified provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision services provided on February 23, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the vision services provided by an OON provider. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the vision services provided on February 23, 2023, 
by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for an in-network inpatient stay provided from 
February 2, 2023, to February 4, 2023. 
 
You asked the Plan to waive the cost for an in-network inpatient stay . You say that you were never informed 
that you would have such a large copayment for this. You are on a limited income and cannot afford 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. Your 
contract with the Plan says that there is a $250 copayment per day for days 1-5, and a $750 deductible which 
applies to inpatient hospital care.  
 
You were in the hospital for 2 days, resulting in a $500 total copayment ($250 x 2 days = $500). You were also 
charged $552.02 towards you $750 deductible ($500 + $552.02 = $1,052.02). 
 
The item or service you asked the Plan to waive the cost for falls within the inpatient hospital care benefit 
category.  The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 copayment per 
day for days 1-5, and a $750 deductible which applies to inpatient hospital care. This cost sharing is a 
contractual obligation that had not been met at the time an in-network inpatient stay was received on February 
2, 2023, to February 4, 2023. Therefore, we decided that the Plan does not have to waive the cost for an in-
network inpatient stay provided from February 2, 2023, to February 4, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the services provided from December 6, 2022 to December 16, 2022. 
 
You asked the Plan to pay for the services. You say that you have called several times because their claims for 
have not been paid. The Plan denied your request. The Plan says that no coverage for this treatment is owed 
under the terms, conditions, limitations, and exclusions contained in the enrollee's plan. 
 
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 records do not support the Plan's denial in this case. The only information 
provided is about enrollment in the Plan. There are no records, claims, or explanation of benefits to show what 
services were provided on any of the dates of service. This means that the Plan has not provided a valid reason 
for denying payment of the services. It is the burden of the Plan to substantiate their denial with evidence. In 
this case, the denial has not been substantiated. Therefore, we decided that the Plan has to pay for the services 
provided from December 6, 2022 to December 16, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for  Medicare Part B drugs administered on 
January 18, 2023. 
 
You asked the Plan to waive the coinsurance for  Medicare Part B drugs . You say that you should not have to 
pay anything extra on top of the copayment you already paid. 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 20% coinsurance for Medicare Part B prescription drugs.  
 
The allowed amount of this drug is $332, resulting in a coinsurance amount of $66.40 ($332 x 20% = $66.40). The enrollee has been asked to pay a $66.40 coinsurance for Medicare Part B drugs. This item/service falls 
within the Medicare Part B prescription drugs benefit category. 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 coinsurance for  Medicare Part B drugs administered on January 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on March 15, 2023. 
 
You asked the Plan to pay for skilled nursing facility care. You say that the assisted living facility is 
responsible to obtain prior authorization for all patients. 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 skilled nursing facility 
care provided on March 15, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on August 30, 2022, 
to September 02, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. 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 $290 
copayment per day for days 1-7 for Medicare-covered hospital stay. Includes inpatient acute, inpatient 
rehabilitation, long-term care hospitals, and other types of inpatient hospital services. Inpatient hospital care 
starts the day you are formally admitted to the hospital with a doctors order. The day before you are 
discharged is your last inpatient day. There were three days. 3 x $290 = $870. Therefore, results in the total 
cost sharing amount of $870. You have been asked to pay a $290 copayment per day for inpatient hospital stay. This item/service falls within 
the inpatient hospital 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 inpatient 
hospital stay on August 30, 2022, to September 02, 2022.