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

 
We decided that the Plan does not have to waive the copayment for the wound care services provided by an in-
network provider from March 13, 2023, to June 8, 2023. 
 
You asked the Plan to waive the copayment for the wound care services. You say that you were not aware that 
the services received in the hospital would be billed as operating room procedures. 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 $335 
copayment for in-network Medicare-covered surgery or other services provided at an outpatient hospital, 
including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $4409.97 copayment for the wound care services because the allowed amount 
for some of the services is less than the $335 copayment. These items/services fall within the outpatient surgery 
and other medical 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 the wound care services provided by an in-
network provider from March 13, 2023, to June 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A4559 billed for date of service April 17, 2023. 
 
You asked the Plan to pay for code A4559. You say that this claim should be processed as in-network. The 
Plan denied your request. The Plan says code A4559 is considered part of the physician service billed on the 
same date (code 93306), so it is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that code A4559 is not separately payable when 
incident to a physician service. Code A4559 was billed on the claim at issue as incident to a physician service, 
so no separate payment can be made. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code A4559 have not been met. Therefore, we decided that the Plan does not have to pay for code 
A4559 billed for date of service April 17, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on August 
23, 2023. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you should not be 
responsible for this 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 $235 
copayment for non-emergency ambulance services. 
 
You have been asked to pay a $235 copayment for the ambulance services. This item/service falls within the 
non-emergency 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 August 23, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided on December 3, 2022, to 
December 6, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says that the enrollee does not meet the requirements 
for approval. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the review has determined that the record showed that at the time of inpatient admission it was 
reasonable for the admitting physician to expect that the enrollees necessary hospital care (including earlier 
emergency department and/or observation care) would span two midnights with supporting documentation of 
the enrollees history and comorbidities, signs and symptoms, current medical needs, and risk of an adverse 
event. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided on December 3, 2022, to December 6, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on August 23, 2023. 
 
You asked the Plan to pay for practitioner services. You say that you are appealing the 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 practitioner services 
provided on August 23, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a transrectal ultrasound provided on March 
02, 2023. 
 
You asked the Plan to waive the copayment for a transrectal ultrasound. You say that you cannot afford 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 $175 
copayment for other Medicare-covered radiological diagnostic services, including ultrasounds. 
 
You have been asked to pay a $175 copayment for a transrectal ultrasound. This item/service falls within the 
other Medicare-covered radiological diagnostic services, including ultrasounds 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 transrectal ultrasound provided on March 02, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance ride provided on May 27, 
2023. 
 
You asked the Plan to waive the copayment for an ambulance ride. You say that you were not expecting all 
these copayments, and were told that there would not be a 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 ambulance services. 
 
You have been asked to pay a $275 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 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the manual therapy techniques (97140) 
application of modality to one or more areas; traction, mechanical (97012) therapeutic exercises (97110) 
comprehensive metabolic panel (80053) lipid panel test (80061) thyroid stimulating hormone (TSH) (84443) 
and total knee arthroplasty (27447) provided January 25, 2023, to March 13, 2023. 
 
You asked the Plan to waive the copayment for the outpatient, laboratory and surgical services. You say that 
when you made your appointment for surgery, you were told you would not have to pay anything and have no 
out of pocket expenses. You are on a fixed income and cannot afford such an 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 50% 
coinsurance for each Medicare covered chiropractic visit, $30 copay for each Medicare covered laboratory 
service, 50% coinsurance for each Medicare covered outpatient surgery at an outpatient hospital facility and 
$30 copay for Medicare covered physician specialist services (including surgery second opinion telehealth 
services, home infusion professional services, and urgently needed services).  
 
You have been asked to pay $5,881.94 for the outpatient, laboratory and surgical services. The only 
chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records 
show that the denied chiropractic services at issue were not manual manipulation of the spine. Page 126 of the 
EOC says when you receive care from an out of network provider, you are only responsible for paying your 
share of the cost. Your share of the cost may be higher for an out of network provider than for a network 
provider. These items/services fall within the Chiropractic services; Outpatient diagnostic tests and therapeutic 
services and supplies; Outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers and Physician/Practitioner services, including doctor's office visits benefit 
categories. 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 manual therapy techniques (97140) 
application of modality to one or more areas; traction, mechanical (97012) therapeutic exercises (97110) 
comprehensive metabolic panel (80053) lipid panel test (80061) thyroid stimulating hormone (TSH) (84443) 
and total knee arthroplasty (27447) provided January 25, 2023, to March 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 4, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
October 4, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a nasal endoscopy provided on September 
06, 2023. 
 
You asked the Plan to reduce the copayment for a nasal endoscopy. You say that you think that the copayment 
should be lower. 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 $295 
copayment for each Medicare-covered outpatient hospital facility visit. 
 
You have been asked to pay a $295 copayment for a nasal endoscopy. This item/service falls within the each 
Medicare-covered outpatient hospital facility 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. However, since the allowed amount is less than the standard 
copayment, you only owe $176.41. Therefore, we decided that the Plan does not have to reduce the copayment 
for a nasal endoscopy provided on September 06, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes E2103 and A4239 provided on June 27, 
2023. 
 
You asked the Plan to pay for procedure codes E2103 and A4239. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the provider is not enrolled in 
the Medicare program. 
 
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 procedure codes E2103 and A4239 
provided on June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99214) arthrocentesis, aspiration, 
bursa injection (26005), and injection, dexamethasone sodium phosphate (J1100) provided on July 8, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient visit. You say that the provider told you that they were in network. 
You would not have gone to this provider if you had known they were out of network.  The Plan denied your 
request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 
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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 outpatient office visit (99214) arthrocentesis, aspiration, bursa injection (26005), and injection, 
dexamethasone sodium phosphate (J1100) provided on July 8, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 22, 2023, by an 
out-of-network (OON) provider.  
 
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 the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide OON 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 laboratory services provided on August 22, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies billed with code A4239 for June 27, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the provider is not Medicare-certified. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are 
furnished by a provider or supplier enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. The file shows that the provider was not Medicare-certified for the 
dates of service at issue. Therefore, we decided that the Plan does not have to pay for the supplies billed with 
code A4239 for June 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine panel provided on September 18, 2023. 
 
You asked the Plan to pay for the urine panel. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
 We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine panel provided on September 18, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
April 06, 2023, to April 12, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you do not understand 
the cost sharing. 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 $195 
copayment for inpatient hospital care. 
 
You have been asked to pay a $195 copayment for the 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. You have been asked to pay a total of $975 for the inpatient hospital stay ($195 copayment 
x 5 days = $975). Therefore, we decided that the Plan does not have to waive the copayment for the inpatient 
hospital stay provided on April 06, 2023, to April 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided on March 
24, 2023, to April 10, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the item is not a covered benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided on March 24, 2023, to April 10, 2023.