Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a rollator walker for the enrollee. 
 
You asked the Plan to pre-approve the walker. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation that the present rollator is broken beyond repair. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 walker. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided records do not document that the enrollee's walker from 5/28/21 has reached its 
reasonable useful lifetime or that it has been stolen, destroyed, or irreparably damaged. 
 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 walker have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a rollator walker for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism. 
 
You asked the Plan to pre-approve the mechanism. You say that this is medically necessary. The Plan denied 
your request. The Plan says the information received and available for review does not indicate any diagnosis 
of severe arthritis of the hip/knee or other neuromuscular diseases. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
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 mechanism. Our reviewer says that 
the requested mechanism is not medically reasonable or necessary. Our physician reviewer found that the 
records report severe arthritis of the spine and severe vascular disease but not severe arthritis of the hip or a 
neuromuscular disease. You are reported to need assistance with all transfers. 
 
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 mechanism have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a seat lift mechanism.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiation therapy on April 06, 2022, to 
April 25, 2022. 
 
You asked the Plan to waive the copayment for radiation therapy. 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 $60 
copayment for Medicare-covered therapeutic radiology services. Covered service include but are not limited to 
other outpatient diagnostic tests. There were 6 visits. $60 x 6 = $360. Therefore, results in the total cost sharing 
amount of $360.  
 
You have been asked to pay a $60 copayment for each radiation therapy. Radiation therapy falls within the 
Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for radiation therapy on April 06, 2022, to April 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for  urostomy supplies provided on May 25, 
2022. 
 
You asked the Plan to waive the copayment for urostomy supplies. You say that you have never had a charge 
like this before. 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 this item is 
$63.90, resulting in a coinsurance amount of $12.78 ($63.90 x 20% = $12.78). 
 
You have been asked to pay a $12.78 coinsurance for urostomy supplies. Urostomy supplies falls within the 
durable medical equipment (DME) and related supplies benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for  urostomy supplies provided on May 25, 2022.  Your complaint about feeling discriminated against is not a valid appeal for medical coverage. This part of 
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for infusions provided on December 8, 2021. 
 
You asked the Plan to waive the coinsurance for infusion. You say that this is an outrageous price to pay and 
the Plan didn't let you know what the cost would be. 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 Medicare Part B Prescription Drugs. The allowed amount of this item is $21,101.60, resulting 
in a coinsurance amount of $4220.32 ($21,101.60 x 20% = $4220.32) but member only had $3,106.83 left of 
their Out-of-Pocket Maximum. 
 
You have been asked to pay a $3,106.83 coinsurance for infusion. Infusion 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 infusions provided 
on December 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a bone scan provided on May 6, 2022. 
 
You asked the Plan to waive the copayment for a bone scan. You say that you thought this was a preventative 
test and that it would not have a 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 $45 
copayment for physician/practitioner services, including doctor's office visits.  
 
You have been asked to pay the allowed amount of $39.76, which is less than the $45 copayment for a bone 
scan. A bone scan falls 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 a bone scan provided on May 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a dermatology visit provided on May 10, 
2022. 
 
You asked the Plan to waive the copayment for a dermatology visit. You say that you feel you were 
misdiagnosed and so you should not have to pay a 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 $45 
copayment for Physician/Practitioner services, including doctors office visits.  
 
You have been asked to pay the allowed amount of $35.44, which is less than the $45 copayment for a 
dermatology visit. A dermatology visit falls within the Physician/Practitioner Services, Including Doctors 
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 a dermatology visit provided on May 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for office visit on June 02, 2022. 
 
You asked the Plan to waive the coinsurance 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 30% 
coinsurance for out-of-network provider and professional services at primary care physicians (PCP) office or 
specialists office. Covered services include medically-necessary medical care or surgery services furnished in 
a physician's office, certified ambulatory surgical center, hospital outpatient department, or any other location 
and consultation, diagnosis, and treatment by a specialist. The provider billed in the amount of $227 and the 
allowed amount is $90.90. $90.90 x 30% = $27.27. Therefore, results in the total cost sharing amount of 
$27.27. 
 
 
 You have been asked to pay a 30% coinsurance 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 coinsurance for office visit on June 02, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the colonoscopy with polyp removal 
provided on May 16, 2022. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that at no time was it mentioned that 
the procedure was anything other than a screening 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 $325 
copayment for outpatient surgical services.  
 Medical records show that polyps were removed during your colonoscopy. Therefore, the colonoscopy is 
considered diagnostic, and the outpatient surgery copayment applies. You have been asked to pay a $325 
copayment for outpatient surgical services for the colonoscopy. The colonoscopy falls within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the colonoscopy with polyp removal provided 
on May 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyaluronan or derivative, Monovisc, for intra-articular 
injection, per dose (J7327). 
 
You asked the Plan to pre-approve Monovisc injection. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the documentation reviewed 
does not show medical necessity as there is no records that the enrollee had a poor response to the other drug 
first.  
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Monovisc injection. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a diagnosis of Unilateral primary osteoarthritis of the right knee. 
Supartz was administered in the right knee on August 9, 2022, August 15, 2022, and August 23, 2022. Follow-
up in the office was to be in one month if pain persists or recurs. The case file does not contain documentation 
of follow-up since then. The documentation does not support that the enrollee has had a trial and inadequate 
response or intolerance to two preferred hyaluronan agents Euflexxa, Supartz Fx, Durolane, or Gelsyn-3, or if 
the preferred agent is not acceptable due to contraindication including hypersensitivity or allergy to one of the 
following: avian or avian-derived agents, including Gel-One, Hyalgan, Orthovisc, Supartz Fx, Synvisc agents, 
Triluron, and Visco-3, or gram-positive bacterial proteins, including Durolane, Euflexxa, Gel- Syn, GenVisc, 
Hymovis, Monovisc, Sodium hyaluronate, and TriVisc. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Monovisc injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Hyaluronan or derivative, Monovisc, for intra-articular injection, per dose (J7327).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for labs provided on September 9, 2021. 
 
You asked the Plan to waive the copayment for labs. You say that you had seen your prime care provider the 
same day and should not have to pay a second copayment. The Plan denied your request. The Plan says the 
copayment was applied 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 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay a $20 copayment for labs. Labs fall 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 
labs provided on September 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retreatment of previous root canal therapy - molar 
(D3348) and cone beam computed tomography (CT) capture and interpretation with limited field of view  less 
than one whole jaw (D0364) provided March 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel you were given confusing or incorrect 
information by plan representatives. The Plan denied your request. The Plan says your benefit for the root canal 
has already been exhausted and the cone beam CT scan is not a covered service. The Plan additionally says that 
they reviewed the call logs and found you were told that one root canal is covered and that cone beam CT scans 
were not inquired about or discussed. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the root canal retreatment was exhausted on the same date of service, March 25, 2022. 
Additionally, the cone beam CT scan is not among your covered benefits.  Therefore, we decided that the Plan 
does not have to pay for the retreatment of previous root canal therapy - molar (D3348) and cone beam 
computed tomography (CT) capture and interpretation with limited field of view  less than one whole jaw 
(D0364) provided March 25, 2022.  
 
Your complaints about issues with finding a provider and potentially receiving confusing or incorrect 
information from plan representatives are not valid appeals for medical coverage. This part of your complaint is 
a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these 
types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a surgical mesh provided on April 11, 
2022. 
 
You asked the Plan to waive the coinsurance for a surgical mesh. You say that you were told you would only 
have to pay a $50 copayment, you did not have control over what the provider used in this procedure. The Plan 
denied your request. The Plan says the coinsurance that was 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 prosthetic devices and related supplies. The allowed amount of this mesh is $608.76, resulting 
in a coinsurance amount of $121.75 ($608.76 x 20% = $121.75). 
 
You have been asked to pay a $121.75 coinsurance for a surgical mesh. a surgical mesh falls within the 
prosthetic devices 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 surgical mesh provided on April 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Onabotulinumtoxin (Botox) injection. 
 
You asked the Plan to pre-approve Botox. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Botox is only covered for certain indications. 
 
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 Botox. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of pelvic and perineal pain secondary to degenerative disease of the 
lumbar and sacral spine. There is no documentation that the enrollee has a diagnosis/condition that meets 
Medicare criteria for the requested onabotulinumtoxin (Botox) injections. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Onabotulinumtoxin (Botox) injection.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance on January 11, 2022. 
 
You asked the Plan to waive the copayment for ambulance. 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 $275 
copayment for each Medicare-covered one-way trip via ground ambulance. Covered ambulance services 
include fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that can 
provide care only if they are furnished to a member whose medical condition is such that other means of 
transportation could endanger the persons health or if authorized by the plan. 
 
 
 
 
 You have been asked to pay a $275 copayment for ambulance. Ambulance falls within the Ambulance services 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for ambulance on January 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for chiropractic visits provided on April 6, 
2022, and April 20, 2022. 
 
You asked the Plan to waive the copayment for chiropractic visits. You say that you should not have these 
copayments. The Plan denied your request. The Plan says the copayments that were applied were 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 $75 
copayment for out-of-network chiropractic services.  
 
You have been asked to pay a $114.02 copayment for chiropractic visits ($75 + $39.02 = $114.02). 
Chiropractic visits fall within the Out-Of-Network Chiropractic 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 chiropractic visits provided on April 6, 2022, and April 20, 2022.