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

 
We decided that the Plan does not have to reduce the copayment for cataract surgery performed on January 13, 
2022. 
 
You asked the Plan to reduce the copayment for the cataract surgery. You say that you were originally billed 
$150 and that amount should be honored. 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 $220 
copayment for each ambulatory surgical center visit.  
 
You have been asked to pay a $220 copayment for the cataract surgery. The cataract surgery 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 reduce the copayment for cataract surgery performed 
on January 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Office visit on January 28, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you a are requesting a reconsideration 
of the copayment. The Plan denied your request. The Plan says the cost-sharing amount 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 $10 
copayment for Primary Care Physician and $10 copayment for Specialty Care Physician. Covered services 
include: Medically-necessary medical care or surgery services furnished in a physicians office, certified 
ambulatory surgical center, hospital outpatient department, or any other location. 
 
 
 
 
 You have been asked to pay a $10 copayment for office visit. Office visit falls within the Physician/Practitioner 
services, including doctors office visits benefit category. You have a $10 copayment for services obtained 
from an office visit. The allowed amount on this claim is $10. 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 January 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a raised toilet seat provided on December 17, 2021. 
 
You asked the Plan to pay for a raised toilet seat. You say that the raised toilet seat is necessary due to arthritis 
and a torn meniscus. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pay for a raised toilet seat provided on December 17, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for knee braces and suspension sleeves provided on date of 
service October 20, 2021. 
 
You asked the Plan to pay for the knee braces that suspension sleeves. You say that you have provided records 
to support payment. The Plan denied your request. The Plan says there is no medical documentation supporting 
that the doctor ordered these items for the patient. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Specifically, the medical records provided have absolutely no mention of the ordering or 
prescribing of these braces.  There is no mention of any condition even related to the need for knee braces or suspension sleeves in the medical records. Finally, this medical record is not dated, so we cannot ascertain if 
this visit was contemporaneous to the prescription for these items. Therefore, we decided that the Plan does not 
have to pay for knee braces and suspension sleeves provided on date of service October 20, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesia services provided on January 13, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination 
within the allotted time frame. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has provided no supporting evidence for the denial of 
payment for this service based on Medicare coverage criteria. Therefore, we decided that the Plan has to pay 
for the anesthesia services provided on January 13, 2021.  
 
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 waive the deductible for out-of-network (OON) specialist telehealth 
visits provided on March 31, 2021, and May 19, 2021. 
 
You asked the Plan to waive the deductible for the specialist telehealth visits. You say that you tried in-network 
providers and did not have any luck. The Plan denied your request. The Plan says the correct amount was 
applied to your deductible. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $250 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Physician/Practitioner 
Services, Including Doctor's Office Visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $250 deductible which applies to certain items and services. This cost 
sharing is a contractual obligation that had not been met at the time the specialist telehealth visits were received 
on March 31, 2021, and May 19, 2021. Therefore, we decided that the Plan does not have to waive the 
deductible for out-of-network (OON) specialist telehealth visits provided on March 31, 2021, and May 19, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trivisc. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has right knee 
osteoarthritis confirmed on imaging studies. He has not tried and failed the Plan's required drugs, Orthovisc, 
Synvisc, and Synvisc-One. The records do not show that the required drugs would be contraindicated or less 
effective; therefore, Trivisc is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Trivisc.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia 60MG/ML subcutaneous syringe. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the step therapy criteria have not been met. 
 
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 the medication. Our physician reviewer 
found there is no indication that the enrollee has tried and failed the required drug(s). Based on the medical 
records provided and the Medicare-approved major drug compendia there is no indication that the plan's 
required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia 60MG/ML subcutaneous syringe.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an appendectomy performed on January 4, 
2022. 
 
You asked the Plan to waive the coinsurance for the appendectomy. You say that you did not know the surgeon 
was not in-network. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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 $150 
copayment for surgery services at an in-network outpatient hospital.  
 
The file shows that the Plan determined the hospital is in-network. However, the Plan also decided they would 
not reprocess the claim, as it would result in a higher cost share to you. Therefore, you have been asked to pay 
$114.87, which is less than the $150 copayment for the appendectomy at an in-network facility. The 
appendectomy 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 coinsurance 
for an appendectomy performed on January 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for a specialist office visit and 
dexamethosone and triamcinolone injections provided on January 26, 2022. 
 
You asked the Plan to waive the copayment and coinsurance for the office visit and injections. You say that 
you need the services due to your excruciating pain. The Plan denied your request. The Plan says the correct 
copayment and coinsurance was applied. 
 
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 $35 
copayment for each in-person specialist visit. 
 
Your contract with the Plan also clearly cays that you must pay a 20% coinsurance for Part B drugs. 
 You have been asked to pay a $35 copayment for the office visit. The office visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. You have also been asked to 
pay $0.02 for the dexamethosone injection, which is 20% of the allowed amount ($0.13 allowed amount x 20% 
coinsurance = $0.02), and $0.23 for the triamcinolone injection, which is also 20% of the allowed amount 
($1.18 allowed amount x 20% coinsurance = $0.23). The total for the visit is $35.25. 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 and coinsurance for a specialist office visit and dexamethosone and triamcinolone 
injections provided on January 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) provided on 
February 7, 2022. 
 
You asked the Plan to waive the copayment for the EKG. You say that you did not have an EKG done on that 
day. 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 $30 
copayment for non-radiological diagnostic services, such as EKG's.  
 
The record shows that an EKG recording was taken on February 7, 2022. Therefore, you have been asked to 
pay a $30 copayment for the EKG. The EKG 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 an 
electrocardiogram (EKG) provided on February 7, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services provided by Manchester 
Ambulance Club on February 19, 2022. 
 
You asked the Plan to pay for the paramedic intercept services. You say that [Enter appellant's argument from 
appeal letter, e.g. "...you need SNF care."] The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept services provided by Manchester Ambulance Club on February 19, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service February 8, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says procedure code 76705 is bundled into payment for 
code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service February 8, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on December 17, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that the facility requested your services and the 
service provided to the enrollee was medically necessary. The Plan denied your request. The Plan says the 
rendering provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a home health visit provided on December 17, 
2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram (EKG) provided on November 26, 
2021. 
 
You asked the Plan to pay for the EKG. You say that this is not a hospice-related claim and the patient was not 
on hospice on the date of service. The Plan denied your request. The Plan says it is not responsible for these 
services. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated.  
The enrollee ended Medicare Hospice benefits on November 9, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the 
electrocardiogram (EKG) provided on November 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you are experiencing extreme pain on bottom of 
right foot. It is so bad some days you use crutches to walk around the apartment. The Plan denied your request. 
The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for specialist services provided on January 12, 
2022, and March 14, 2022. 
 
You asked the Plan to waive the coinsurance for the specialist services. You say that the Plan representative 
and customer service misinformed you of your costs. The Plan denied your request. The Plan says the correct 
coinsurance was applied. 
 
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 40% 
coinsurance for specialist services with an out-of-network (OON) provider.  
 
You have been asked to pay $65.44 for each visit for the specialist services, which is 40% of the allowed 
amount ($163.59 allowed amount x 40% coinsurance = $65.44). The total for both visits is $130.88. The 
specialist 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 coinsurance for specialist services provided on January 12, 
2022, and March 14, 2022.  
 
Your complaint about the Plan representatives and customer service agents giving misinformation 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that your wife has a broken leg and is unable to 
shower or take bath, so they need this item. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a comprehensive hearing test performed on 
May 3, 2021. 
 
You asked the Plan to waive the copayment for the hearing test. You say that you were under the impression 
that there were no copayments under this insurance plan. 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 $40 
copayment per visit for hearing exams.  
 
You have been asked to pay a $40 copayment for the hearing test. The hearing test falls within the Hearing 
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 a comprehensive hearing 
test performed on May 3, 2021.