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

 
We decided that the Plan does not have to pay for medical services provided on July 21, 2020. 
 
You asked the Plan to pay for the medical services. You say that you believe the Plan's failure to accept your 
claim is inappropriate. The Plan denied your request. The Plan says you did not file your claim timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the medical services was not filed until September 30, 2021. You have 
provided no evidence showing that this claim was filed within one year of the date of service. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for medical services provided on July 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided on November 12, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the out-of-network acupuncture services. You say that you called the Plan and 
were told that no authorization was needed. The Plan denied your request. The Plan says unauthorized, non-
plan care is not covered. The Plan also says that they pulled up the phone records from the phone call you 
referenced (call 67241087).  This call was not in reference to this specific enrollee. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The  provider in this case is not a network provider with the Plan. There is no coverage for out-of-network 
acupuncture services under this enrollee's Plan. The Plan did not pre-approve the services at issue. We found no 
exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not 
have to pay for acupuncture services provided on November 12, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that you need the scooter to get to your shed. The 
Plan denied your request. The Plan says you have not had an in-home assessment. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
We looked at the file and the rules. The records show that you require use of the scooter for distances in the 
community. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside 
the home. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Coflex interspinous stabilization device. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee's symptoms have limited 
his ability to perform activities of daily living. The Plan denied your request. The Plan says the device is 
considered investigational for all indications. 
 
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 requested services. Our physician 
reviewer found that the Coflex device is experimental. More research is needed to show safety and efficacy of 
the procedure for low back pain. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Coflex interspinous stabilization device.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a lumbar magnetic resonance imaging (MRI) for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says that a study similar to this one has already been requested. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
requested MRI is medically reasonable and necessary. Our physician reviewer found the computed tomography 
(CT) scans were done without intrathecal contrast, and this limits the visualization of the soft tissue structures, 
such as existing nerve roots. The boney elements are better seen with CT but not the neuro structures. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
a lumbar magnetic resonance imaging (MRI) for the enrollee.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Latuda. 
 
You asked the Plan to pre-approve Latuda. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested drug is self-administered. The Plan says 
self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the 
requested drug is not covered under Medicare Part B. 
 
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 Latuda.  
 Benefits for Latuda 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids you purchased from on January 6, 2022. 
 
You asked the Plan to pay for the hearing aids. You say that you were told that you would be reimbursed for 
part of the cost of new hearing aids. The Plan denied your request. The Plan says you did not use the designated 
Plan hearing aid vendor. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plan's designated hearing aid provider.  You did not use the Plan's 
designated hearing aid vendor when you purchased the hearing aids on January 6, 2022. 
 
Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. 
Therefore, we decided that the Plan does not have to pay for hearing aids you purchased from on January 6, 
2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency department services provided 
on December 9, 2021. 
 
You asked the Plan to waive the copayment for emergency department services. You say that you should not 
have a copayment because the provider advised you to go to the emergency room as the provider did not have 
the testing equipment in the facility. The Plan denied your request. The Plan says you were 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 $90 
copayment for each Medicare-covered emergency room visit.  
 
You have been asked to pay a $90 copayment for emergency department services. Emergency department 
services fall 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 emergency department services provided on December 9, 2021.
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 10, 2021, to March 11, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were not charged 
for the last two previous hospital stays. 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 in-
network $350 per day, days 1-5; $0 per day, days 6-90; $0 copay for additional days for inpatient hospital 
stays. 
 
 You have been asked to pay $350 for the inpatient hospital stay. Inpatient hospital stays fall 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 10, 2021, to March 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided on July 8, 2021. 
 
You asked the Plan to waive the copayment for an x-ray. You say that this x-ray was used solely as post-
operation to evaluate your hip replacement surgery. You say that you would like this copayment to be 
reviewed. 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 a $30 
copayment for each Medicare-covered standard x-ray service.  
 
 
 
 You have been asked to pay a $30 copayment for an x-ray. The x-ray 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 x-ray provided on July 8, 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 have foot pain, flat feet, and have been 
advised inserts would assist with walking. Your borderline diabetic, morbidly obese and walking will help to 
lose weight. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided by a 
network facility from January 24, 2022, to January 25, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you are appealing this 
claim. The Plan denied your request. The Plan says you have been asked to pay 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 $350 
copayment for each day for days 1 to 5 each time you are admitted for Medicare-covered hospital care.  
 
 You have been asked to pay a $350 copayment for the inpatient hospital stay. The 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 by a network facility from January 24, 2022, to January 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
November 18, 2021, to November 30, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that neither you nor your 
family asked to have a private room. 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 $295 
copayment per day for days 1-7 for an inpatient hospital stay. The contract also says that there is a $0 
copayment for days 8-90. The contract also says that coverage for inpatient hospital care includes semi-private room and private rooms. 
 
According to the EOC, the cost share is the same for a semi-private room and a private room. You have been 
asked to pay a total of $2,065, which is a $295 copayment per day for days 1-7 for an inpatient hospital stay 
($295 copayment x 7 days = $2,065). There is no charge for days 8-90. 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 an inpatient 
hospital stay provided from November 18, 2021, to November 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on July 28, 2021, by an OON 
provider. 
 
You asked the Plan to pay for the physician services. You say that it was the facilities responsibility to obtain 
the authorization and it was medically necessary to treat the enrollee. The Plan denied your request. The Plan 
says the rendering provider is an OON provider and there was no approved authorization. 
  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 the physician services provided on July 28, 2021, 
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 11, 2021, by an OON 
provider. 
 
You asked the Plan to pay for the office visit. You say that you have provided the medical records and would 
like the claim reprocessed for payment. The Plan denied your request. The Plan says the rendering and 
referring providers are both OON providers and there was no 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 an office visit provided on October 11, 2021, by 
an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Outpatient Hospital Services on July 30, 
2021 to August 3, 2021. 
 
You asked the Plan to waive the copayment for Outpatient Hospital Services. You say that you would like to 
appeal the cost share. The Plan denied your request. The Plan says the cost share 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 a $175 
copayment for Outpatient Hospital Services.  
 
You have been asked to pay a $175 copayment for Outpatient Hospital Services. Outpatient Hospital Services 
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 Outpatient 
Hospital Services on July 30, 2021 to August 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a nivolumab injection and drug 
administration provided on August 30, 2021. 
 
You asked the Plan to waive the coinsurance for an injection and drug administration. You say that you cannot 
afford these charges as you live on social security. You also say the injection caused side effects and did not 
work for you. 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 20% 
coinsurance for in-network Part B drugs and administration.  
 
 The record shows this claim was approved, and you have a cost share amount. You have been asked to pay 
$2,857.14, which is 20% coinsurance of the allowed amount for an injection ($14,285.69 allowed amount x 
20% coinsurance = $2,857.14). You have also been asked to pay $67.88, which is 20% of the allowed amount 
for drug administration ($339.42 allowed amount x 20% coinsurance = $67.88). You have been asked to pay a 
total of $2,925.02 ($2,857.14 coinsurance + $67.88 coinsurance = $2,925.02). An injection and drug 
administration 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 a nivolumab injection and drug administration provided on August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on November 23, 2021, by 
an OON provider. 
 
You asked the Plan to pay for the physician services. You say that a referral is not needed based on your 
contract and you would like the claim reprocessed. 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 the physician services provided on November 23, 
2021, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on December 
8, 2021. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you tried to attend another 
facility but you were turned away. You say that you had no choice but to attend the hospital for the lab service. 
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 a $40 
copayment for lab services only when provided in an outpatient hospital facility.  
 
  
 
 
You have been asked to pay a $40 copayment for laboratory services. The laboratory service 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 laboratory services provided on December 8, 2021.