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

 
We decided that the Plan does not have to waive the copayments for Emergency care and inpatient hospital 
services on February 09, 2022, to February 14, 2022. 
 
You asked the Plan to waive the copayments for emergency care and inpatient hospital services. You say that 
you not advised of the copayments for inpatient services when you signed up for the plan. 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 $90 
copayment per visit for emergency care and $250 copayment per day for days 1-7 per admission for inpatient 
hospital care. There were 5 total days, resulting in a total copayment amount of $1,250. The plan did not apply 
any copayment to the discharge date, February 14, 2002. Therefore, your total copayment is $1,340.    
You have been asked to pay a $90 copayment for emergency care and a $250 copayment for inpatient hospital 
services. Emergency care and inpatient hospital services fall within the Emergency Care and 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 copayments for Emergency care and inpatient 
hospital services on February 09, 2022, to February 14, 2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to reprocess the copayments for the physical therapy services provided from 
September 20, 2021, through September 24, 2021. 
 
You asked the Plan to reprocess the copayments for the physical therapy services. You say that you would like 
these copayments reprocessed. The Plan denied your request. The Plan says that the copayments have 
processed correctly in this case. 
 
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 enrollees must pay a $10 copayment for outpatient rehabilitation services 
received in a specialists office.  
 
The Plan says you must pay a $40 copayment per day for the physical therapy services. Based on the Plan 
contract, however, you cannot be asked to pay more than $10 per day for the physical therapy services. The 
services at issue were not provided in an outpatient hospital. Therefore, we decided that the Plan has to 
reprocess the copayments for the physical therapy services provided from September 20, 2021, through 
September 24, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sales tax (S9999) and delivery/set-up/dispensing (A9901) for 
a COVID-19 test received on January 13, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this service is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that procedure codes A9901 and S9999 are not supported in the medical record. Specifically, S9999 
has a status indicator of I, which means that it is not valid for Medicare purposes. A9901 has a status indicator 
of X, which means that it is excluded from coverage. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for sales tax (S9999) and delivery/set-up/dispensing (A9901) for a COVID-19 test received on January 13, 
2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 
You asked the Plan to pre-approve Eylea. 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. 
 
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 Eylea. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the record does not indicate that the 
enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one 
alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ear procedure provided at your annual 
exam on January 19, 2022. 
 
You asked the Plan to waive the copayment for ear procedure provided at your annual exam. You say that since 
this was your annual exam everything should be covered. The Plan denied your request. The Plan says the 
copayment 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 $5 
copayment for any non-preventative services you receive during your visit.  
 
 You have been asked to pay $5 copayment for an ear procedure provided at your annual exam.  Non- 
preventative services provided at your annual exam 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 ear procedure 
provided at your annual exam on January 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent. 
 
You asked the Plan to pre-approve Dupixent. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Dupixent.  
 
Benefits for Dupixent 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to waive the cost-sharing for an inpatient hospital stay provided from September 
3, 2021, to September 11, 2021. 
 
You asked the Plan to waive the cost-sharing for an inpatient hospital stay. You say that you never received 
such treatment at this facility. The Plan denied your request. The Plan says that the cost-sharing applied was 
correct. 
 
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. The Plan did not include evidence that the services were provided. Therefore, we 
decided that the Plan has to waive the cost-sharing for an inpatient hospital stay provided from September 3, 
2021, to September 11, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS system. 
 
You asked the Plan to pre-approve a CardioMEMS system. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 a CardioMEMS system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollee's clinical 
management. 
 
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 CardioMEMS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS system.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-one (CPT code J7325). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Medicare rules say tier exceptions (co-pay reductions) are not available for 
drugs/devices covered by Part B and Medicare also says drugs/devices covered by Part B cant be covered by 
Part D. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the medication have not been met. When you ask for a higher cost 
drug at a lower cost level (tier) it is called a tiering exception. The Plan follows Medicare rules. The Medicare rule in the Parts C & D Enrollee Grievances, Organizations/Coverage Determinations, and Appeals Guidance 
explains when you can get a tiering exception. It says you cannot get a tiering exception for very high-cost 
drugs on a specialty tier. The information we have says this is a very high-cost drug on a specialty tier. You do 
not qualify for a tiering exception per Medicare rules. Therefore, we decided that the Plan does not have to pre-
approve Synvisc-one (CPT code J7325).  
 
Benefits for the medication 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit and an inpatient 
hospital stay provided from August 22, 2021, to August 30, 2021. 
 
You asked the Plan to waive the copayment for an ER visit and an inpatient hospital stay. You say that you are 
dissatisfied with how the surgery has turned out. 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 $90 
copayment per visit for emergency care. Your contract with the Plan also clearly says that you must pay a $210 
copayment per day for days 1-6 per admission for in-network inpatient hospital care.  
 
 You have been asked to pay a $90 copayment for an ER visit and $1,260 for your inpatient hospital stay ($210 
x 6 days). An ER visit falls within the Emergency Care benefit category. 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 
emergency room visit and an inpatient hospital stay provided from August 22, 2021, to August 30, 2021.  
 
Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist office visits provided on 
November 28, 2021, and December 20, 2021. 
 
You asked the Plan to waive the copayments for specialist office visits. You say that you already paid these 
copayments so you shouldn't have to pay again. The Plan denied your request. The Plan says the copayments 
applied are 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 $15 
copayment for services obtained from specialist a specialist or under certain circumstances, treatment by a 
nurse practitioner or physicians assistant or other non-physician health care professionals in a specialists 
office (as permitted under Medicare rules).  
 
 You have been asked to pay a total of $30 copayment for the two specialist office visits. Specialist office visits 
fall 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 copayments for specialist office visits provided on November 28, 2021, and 
December 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on October 
17, 2021. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that you only went for a COVID-
19 test and did not expect 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 $25 
copayment for each visit to other providers for urgently needed services.  
 
You have been asked to pay a $25 copayment for the urgent care visit. The urgent care visit falls within the 
Urgently Needed 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 an urgent 
care visit provided on October 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 30, 
2021. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says if a laboratory assays two or more genes in a patient in parallel, then those two or more genes 
will be considered part of the same panel. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for laboratory services provided to the enrollee on March 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for wound care and specialist services 
provided on February 8, 2022. 
 
You asked the Plan to waive the copayments for the wound care and specialist services. You say that you feel 
the billing codes were incorrect. 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 $150 
copayment for outpatient hospital surgery services. There may also be additional professional copayments. 
 
Your contract with the Plan also clearly says that you must pay a $30 copayment for each specialist visit. You have been asked to pay a $150 copayment for the wound care. The wound care falls within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. You have also been asked to pay a $30 copayment for the specialist services. The specialist services 
fall within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. The total for 
the visit is $180. 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 wound care and specialist 
services provided on February 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for urgent care visits provided on November 
2, 2021, and November 15, 2021. We also decided that the Plan does not have to waive the copayment for a 
primary care physician (PCP) office visit provided on December 2, 2021. 
 
You asked the Plan to waive the copayments for the urgent care and PCP visits. You say that you disagree with 
the charges since your doctor told you to go to urgent care instead. 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 $45 copayment for each urgent care visit. 
 
Your contract with the Plan also clearly says that you must pay a $10 copayment for each primary care visit. 
 
You have been asked to pay a $45 copayment for each urgent care visit, totaling $90. The urgent care visits fall 
within the Urgently Needed Services benefit category. You have also been asked to pay a $10 copayment for 
the PCP office visit. The PCP office visit falls within the Physician/Practitioner Services, Including Doctor's 
Office Visits benefit category. The total for all visits is $100. 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 urgent care visits provided on November 2, 2021, and November 15, 2021. We also decided that the Plan 
does not have to waive the copayment for a primary care physician (PCP) office visit provided on December 2, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Durable Medical Equipment (DME) on 
January 31, 2022. 
 
You asked the Plan to waive the coinsurance for durable medical equipment (DME). You say that you never 
used it, it just sat in a box. The Plan denied your request. The Plan says the cos-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 20% 
coinsurance for Durable medical equipment (DME) and related supplies. Covered items include, but are not 
limited to: wheelchairs, crutches, powered mattress system, diabetic supplies, hospital beds ordered by a 
provider for use in the home, IV infusion pumps, speech-generating devices, oxygen equipment, nebulizers, 
and walkers. The allowed amount of these items is $1,381.35, resulting in a coinsurance amount of $276.27. 
 
 
 
 You have been asked to pay 20% coinsurance for durable medical equipment (DME). Durable medical 
equipment (DME) 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 coinsurance for Durable Medical Equipment (DME) on January 31, 2022.