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

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
November 13, 2021. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that the type of doctor you 
needed to see wasn't available so the ER doctor requested you be admitted to another hospital. The Plan denied 
your request. The Plan says you have been charged the correct copayment 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 $75 
copayment for Medicare-covered emergency room visits.   
 
You have been asked to pay $75 copayment for an emergency room visit. Emergency room visit falls within 
the Emergency 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 
emergency room visit provided on November 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for primary care physician (PCP) services 
provided on August 18, 2021. 
 
You asked the Plan to waive the copayment for the PCP services. You say that this was your yearly physical 
and you should not have a copayment. 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 $0 copayment for each PCP visit for an annual physical. Any labs or diagnostic procedures are not covered under 
this benefit and you pay your plan cost sharing amount for those services separately. 
 
Your contract with the Plan also clearly says that you must pay a $20 copayment for each PCP visit. 
 
The file shows that during your annual physical, you addressed additional concerns such as arthritis and back 
pain. You also received an injection for the pain. These services go beyond the scope of an annual physical. 
Therefore, you have been asked to pay a $20 copayment for the PCP services. The PCP services 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 primary care physician (PCP) services provided on August 18, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
services are medically necessary. Our physician reviewer found the enrollee does not have documented skilled 
nursing needs. The enrollee does have documented skilled therapy needs. Daily skilled services are required to 
establish a maintenance program and/or to prevent deterioration of the enrollees condition. The enrollees care 
needs, as a practical matter, cannot be provided at a lower level of care given the need to maintain weight 
bearing restrictions and hip precautions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the Centers for Medicare & Medicaid Services 
(CMS) National Coverage Determinations Manual (CMS Pub. 100-03) in Chapter 1, Part 4, Section 280.1 
stipulates that ventilators (E0465, E0466, and E0467) are covered when specific criteria 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 a portable ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found based on the medical records 
provided there is no documentation that you meet the coverage criteria detailed in the Local Coverage 
Determination (LCD): Respiratory Assist Devices - L33800. As stated in the LCD: "Claims for ventilators used 
to provide CPAP or bi-level CPAP therapy for conditions described in this RAD policy will be denied as not 
reasonable and necessary." 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Outpatient hospital observation provided 
from May 11, 2021, to May 13, 2021. 
 
You asked the Plan to waive the copayment for the outpatient hospital observation. You say that the services 
should be covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-
sharing applied correctly based on the services provided. 
 
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 hospital observation.  
 
 
  You have been asked to pay a $325 copayment for the outpatient hospital observation. 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 hospital observation provided from May 11, 2021, to May 
13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for medical eye exams provided on November 
29, 2021 and December 20, 2021. 
 
You asked the Plan to waive the copayment for medical eye exam. You say that you had to see an eye 
specialist after your cataract surgery, so you should not have to pay for these follow up visits. The Plan denied 
your request. The Plan says copayment 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 $35 
copayment for medical eye exam.  
 
  You have been asked to pay a total of $70 for the medical eye exams ($35/visit x 2 visits = $70). Medical eye 
exam falls within the Vision 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 
medical eye exams provided on November 29, 2021 and December 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for remote pacemaker evaluation services 
provided on January 4, 2022. 
 
You asked the Plan to reduce the copayment for the remote pacemaker evaluation. You say that your 
copayment for 2022 should only be $20 for the services. 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 $25 
copayment for non-radiological diagnostic services.  
 
You have been asked to pay a $25 copayment for the remote pacemaker evaluation. The remote pacemaker 
evaluation 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 reduce the copayment for remote pacemaker evaluation services provided on January 
4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. The Plan denied your request. The Plan says the requested use 
of the ventilator is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a ventilator. Our physician reviewer 
found that you have COPD and chronic respiratory failure with hypercapnia. The pulmonary office consult 
documents that you had evidence of hypercapnic respiratory failure while in the hospital. The plan was to start 
treatment with noninvasive support at night. While you have respiratory failure due to COPD, products 
classified as E0466 when used to provide CPAP or BiPAP shall not be paid in the FSS payment category, 
regardless of the underlying medical condition. There is no documentation to suggest a BiPAP with back up 
rate and AVAPS with or without Auto-EPAP was utilized and failed. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the endoscopy provided on December 21, 
2021. 
 
You asked the Plan to waive the copayment for endoscopy. You say that your last colonoscopy was done back 
in 2015. It is your understanding the charge should have been paid in full through Medicare and insurance. The 
Plan denied your request. The Plan says copayment 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 $235 
copayment for in-network, Medicare-covered surgery or other services provided to you at an ambulatory 
surgical center, including but not limited to hospital or other facility charges and physician or surgical charges.   
You have been asked to pay $235 copayment for endoscopy. The endoscopy falls 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 endoscopy provided on 
December 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a myocardial perfusion stress study 
provided on May 21, 2021. 
 
You asked the Plan to waive the copayment for a perfusion stress study. You say that the stress test procedure 
was done with for transplant evaluation and the transplant coordinator set it up. 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 $75 
copayment for in-network outpatient diagnostic radiology services.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$75 copayment for a perfusion stress study. A perfusion stress study 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 a myocardial perfusion stress study provided on May 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is documentation that enrollee is already refusing therapy and care by nursing 
staff at the custodial and skilled nursing facility level thus would not be reasonably expected to participate in an intense therapy regimen in an IRF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive coinsurance for the walker provided on June 19, 2021. 
 
You asked the Plan to waive coinsurance for the walker. You say that you would like the coinsurance to be 
written off because you are having money problems.  The Plan denied your request. The Plan says coinsurance 
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 in-network and out-of-network, Medicare-covered benefits.  
 
You have been asked to pay $18.92, which is 20% of the allowed amount for the walker. The allowed amount 
is $94.61 (20% x $94.61 = $18.92). The walker 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 coinsurance for the walker provided on 
June 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for iron infusions provided from July 9, 2021, 
to July 30, 2021. 
 
You asked the Plan to waive the copayments for iron infusions. You say that you received the bill for the 
infusions, and you thought it was exceptionally high. You also say that you have called the hospital, Medicare, 
and the Plan each one gave you different answers. 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 $225 
copayment for outpatient surgery or other services provided to you at an ambulatory surgical center, including 
but not limited to hospital or other facility charges.  The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
total of $1,019.16 for iron infusions from July 9, 2021, to July 30, 2021. 
 
Date of Service Code Copayment Allowed Amount 
July 9, 2021 96374 $225 $198.54 
July 12, 2021 96374 $225 $198.54 
July 16, 2021 96374 $225 $198.54 
July 21, 2021 96374 $225 $198.54 
July 30, 2021 96375 $225 $39.03 
July 30, 2021 96374 $225 $185.97 
Total   $1,019.16 
 
Iron infusions 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 copayments 
for iron infusions provided from July 9, 2021, to July 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vraylar 1.5mg capsules. 
 
You asked the Plan to pre-approve Vraylar. You say that Vraylar is medically necessary. The Plan denied your 
request. The Plan says this drug is not eligible for coverage under the Part B medical 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 Vraylar 1.5mg capsules.  
 
Benefits for Vraylar 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the epidural steroid injection provided on 
November 4, 2021. 
 
You asked the Plan to waive the copayment for the epidural steroid injection. You say that you received the 
injection in the office, and you would like a reduction of the charge. The Plan denied your request. The Plan 
says copayment 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 $370 
copayment for in-network, Medicare-covered surgery or other services provided to you 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 $370 copayment for the epidural steroid injection. The epidural steroid injection 
falls 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 epidural 
steroid injection provided on November 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided on May 
10, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you did get prior approval 
and were advised this was a charge for an in hospital semi private room. The Plan denied your request. The 
Plan says you have been charged the correct copayment 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 $395 
copayment per day for days 1 through 5 for covered hospital care. Thereafter, you page a $0 copayment for 
additional Medicare-covered days during your hospital admission.  
 
You have been asked to pay $395 copayment per day for days 1 through 5 for covered hospital care. 
Thereafter, you page a $0 copayment for additional Medicare-covered days during your hospital admission. 
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 an inpatient hospital stay provided on May 10, 2021.