Persius/hicric huggingface dataset:
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 requested LTACH admission is 
medically necessary. The Plan denied your request. The Plan says the requested LTACH admission is not 
medically necessary. 
 
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 admission is not medically necessary. Our physician reviewer found the enrollee 
appears to be stable and improving and should only require short-term additional acute care services that can 
safely be administered at the current facility until more appropriate for a lower level of care. The enrollee does 
not require services at the LTACH that are not already available at the current facility. There are no services at 
the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer 
to LTACH is not medically necessary as it would not be clinically advantageous at this time. 
 
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 injection provided on November 29, 
2021. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you never had to pay this much in 
the past and you cannot afford the price increase. 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 each Medicare covered Part B drug.  
 
You have been asked to pay $200.84 which is 20% of the allowed amount for an injection. The allowed amount 
is $1,004.20 (20% x $1,004.20 = $200.84). Injections fall 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 injection provided on 
November 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74018-26 billed for date of service March 16, 
2022. 
 You asked the Plan to pay for procedure code 74018-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 74018-26 is bundled into 
payment for code 74019-26. 
 
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 
74018-26 is a column II code to column I code 74019-26. 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 74018-26 billed for date of service 
March 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy on October 29, 2021. 
 
You asked the Plan to waive the coinsurance for chemotherapy. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says the cost sharing you are being charged 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 a 20% 
coinsurance for Medicarecovered Part B Chemotherapy drugs and other Part B 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 selfadministered 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 $10,854.10 and the allowed amount is $797.75. $797.75 x 20% = $159.55. Therefore, results 
in the total cost sharing amount of $159.55. 
 
 You have been asked to pay a 20% coinsurance for chemotherapy. Chemotherapy 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 
chemotherapy on October 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out-of-network specialist visit, and x-
ray provided on March 16, 2022. 
 
You asked the Plan to waive the coinsurance for an out-of-network specialist visit and x-ray. You say that you 
should not have to pay this coinsurance as you were unaware of it. The Plan denied your request. The Plan says 
the coinsurance applied was 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 a 50% 
coinsurance for out-of-network outpatient diagnostic tests and physician/practitioner services. The allowed 
amount of the x-ray is $142.05 resulting in a coinsurance amount of $71.03 ($142.05 x 50% = $71.03) and a 
specialist visit with the allowed amount of $139.96 resulting in a coinsurance amount of $69.98 ($139.96 x 
50% = $69.98). The total of these together is $71.03 + $69.98 = $141.01. 
  
You have been asked to pay a $141.01 coinsurance for an out-of-network specialist visit and x-ray.  An out-of-network specialist visit, and x-ray falls within the Out-Of-Network Outpatient Diagnostic Tests and 
Physician/Practitioner Services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan.  
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the coinsurance for an out-of-network specialist visit, and x-ray 
provided on March 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
March 26, 2022, to March 31, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you should only have 
been there two days. You say that you should not have to pay for the other three days. 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 $385 
copayment each day for days 1-5 for Inpatient Hospital Care.  
 
You have been asked to pay $1925 copayment for a five-day inpatient hospital stay ($385 per day x 5 days = 
$1925). An inpatient hospital stay 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 the inpatient hospital stay provided from March 26, 2022, to March 
31, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the Inflectra infusion provided on March 22, 
2022. 
 
You asked the Plan to waive the cost share for the Part B drug. You say that you will need these infusions for 
the rest of your life, and you need assistance paying for your infusions. 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 20% 
coinsurance for Part B drugs.  
 
You have been asked to pay a 20% coinsurance for the Inflectra infusion for a total of $405.70 ($2028.50 the 
allowed amount x 20% coinsurance = $405.70). Part B drugs fall 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 cost share for the Inflectra infusion provided on 
March 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve Freestyle Libre CGM. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for the requested device. 
 
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 
Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve Eliquis. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not a covered benefit. 
 
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 pre-approve Eliquis.  
 
Benefits for Eliquis 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy (EGD) 
provided on April 27, 2022. 
 
You asked the Plan to waive the copayment for an EGD. You say that you were not made aware about the 
copayment and would not have gotten this test done if you had. Therefore, you should not have to pay the 
copayment. The Plan denied your request. The Plan says the copayment applied was 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 a $325 
copayment for outpatient surgery.  
 
You have been asked to pay a $325 copayment for an EGD. An EGD falls within the Outpatient Surgery, 
Including Services Provided at a 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 an esophagogastroduodenoscopy (EGD) 
provided on April 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound of the abdomen provided on 
October 23, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you were told there would be no 
copay. You asked for a review because this was part of your colonoscopy. 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 $50 
copayment for ultrasounds.  
 
You have been asked to pay a $50 copayment for an ultrasound. The ultrasound 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 copayment for the ultrasound of the abdomen provided on October 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on December 16, 2020. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged 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 a $45 
copayment for each Medicare-covered specialist visit. Covered services include consultation, diagnosis, and 
treatment by a specialist. 
 
You have been asked to pay a $45 copayment for office visit. Office visits fall within the Physician/Practitioner 
services, including doctor's office visits benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for office visit on December 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for 12 outpatient procedures provided from 
February 7, 2022, to March 25, 2022. 
 
You asked the Plan to waive the copayment for an outpatient procedure. You say that you cannot afford this 
copayment and that it is too costly. The Plan denied your request. The Plan says the copayment applied was 
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 a $295 
copayment for outpatient hospital surgical services. You had 12 services, each was charged an allowed $194.82 
which is less than the $295 copayment (12 x $194.82 = $2,337.84). 
 
You have been asked to pay a $2,337.84 copayment for an outpatient procedure. An outpatient procedure falls 
within the Outpatient Hospital Surgical 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 12 outpatient procedures provided from February 7, 2022, to March 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Humulin R. 
 
You asked the Plan to pre-approve Humulin R. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested drug is not a covered benefit. 
 
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 pre-approve Humulin R.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a walker, oxygen system, and an oxygen 
concentrator provided on March 18, 2022. 
 
You asked the Plan to waive the coinsurance for a walker, oxygen system, and an oxygen concentrator. You 
say that you should not have to pay this coinsurance amount. The Plan denied your request. The Plan says the 
coinsurance applied was 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 a 20% 
coinsurance for durable medical equipment (DME) and related supplies. The allowed amount of a walker is 
$66.85 resulting in a coinsurance amount of $13.37 ($66.85 x 20% = $13.37). 
The allowed amount of this oxygen system is $22.16 resulting in a coinsurance amount of $4.43 ($22.16 x 20% 
= $4.43). 
The allowed amount of this oxygen concentrator is $112.33 resulting in a coinsurance amount of $22.47 
($112.33 x 20% = $22.47). Totals: $13.37 + $4.43 + $22.47 = $40.27. 
 You have been asked to pay a $40.27 coinsurance for a walker, oxygen system, and an oxygen concentrator. a 
walker, oxygen system, and an oxygen concentrator fall 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 a walker, oxygen system, and an oxygen 
concentrator provided on March 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a mental health visit provided on March 17, 
2022. 
 
You asked the Plan to waive the deductible for a mental health visit. You say that you cannot afford this 
deductible amount per appointment. The Plan denied your request. The Plan says the deductible amount 
applied was 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 a $5,150 
deductible for section 1.2 combined out-of-pocket amount.  
 
You have been asked to pay a $69.46 deductible for a mental health visit. A mental health visit falls within the 
Section 1.2 Combined Out-Of-Pocket Amount 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 a mental health visit provided on March 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injection on March 15, 2022. 
 
You asked the Plan to waive the coinsurance for injection. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged 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 a 20% 
coinsurance for Medicare-covered Part B chemotherapy drugs and other Part B 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 $33,539.24 and the allowed amount is $2,133.41. $2,133 x 20% = $426.68. Therefore, results 
in the total cost sharing amount of $426.68. 
 
 
 You have been asked to pay a 20% coinsurance for injection. Injections fall 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 injection on March 
15, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the Part B drugs provided from February 
8, 2021, November 8, 2021. 
 
You asked the Plan to waive the copayments for the Part B drugs. You say that you have been billed four 
copayments of $5.58. You say that now that you go to a new facility the provider is billing you for the 
medication. 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 20% 
coinsurance for each Part B drug.  
 
You have been asked to pay a 20% coinsurance for the Part B drugs for a total of $22.32. Part B drugs fall 
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 
copayments for the Part B drugs provided from February 8, 2021, November 8, 2021.