Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient mental health services provided 
from January 8, 2020, to January 14, 2020. 
 
You asked the Plan to waive the copayment for the inpatient mental health services. You say that you were 
forced to stay at the hospital against your will. 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 $230 per 
day for days 1-7 and $0 per day after day 7 for each hospital stay.  
 
The file shows that you were in the hospital from January 8, 2020, to January 14, 2020, but there is no 
copayment for the discharge date. Therefore, you have been asked to pay $230 per day for the first 6 days of inpatient mental health services. The total for your stay is $1,380 ($230 copayment x 6 days = $1,380). The 
inpatient mental health services fall within the Inpatient Mental Health 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 inpatient mental health services provided from January 8, 2020, to 
January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to lower the copayment for an outpatient surgery provided by on 
November 11, 2021. 
 
You asked the Plan to lower the copayment for the outpatient surgery. You say that you believe the copayment 
is wrong and the copayment should be less than what it is because it was a diagnostic test. The Plan denied 
your request. The Plan says the provider billed for diagnostic procedure so the proper copayment for outpatient 
surgery 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 $250 
copayment for each Medicare-covered outpatient hospital service, including observation, outpatient surgery or 
procedure.  
 
  You have been asked to pay a $250 copayment for the outpatient surgery. The outpatient surgery falls within 
the Outpatient hospital observation 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 lower the copayment for an 
outpatient surgery provided by on November 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device. 
 
You asked the Plan to pre-approve a Vertiflex Superion Interspinous device. 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 Vertiflex Superion Interspinous 
device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, 
the request for Vertiflex Superion interspinous device at L4-5 is not medically reasonable or 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 Vertiflex Superion Interspinous device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Simponi infusions to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the Simponi infusions. You say that the services are medically necessary 
and you are comfortable with this provider. The Plan denied your request. The Plan says the services are non-
emergent and there are network providers available. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve Simponi 
infusions to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
August 5, 2021, through August 6, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service 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 $200 per 
day, for days 1-5 and $0 after day 5 each time you are admitted to an acute care hospital. This applies to all 
admissions, including a transfer from another facility such as an acute rehabilitation or skilled nursing. You have been asked to pay $200 ($200 copayment x 1 day) for the inpatient hospital care provided. 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 care provided from August 5, 2021, 
through August 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from 
September 4, 2021, to September 5, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were not in the 
ICU, only the emergency 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 $225 per 
day for days 1-7 and $0 per day for days 8-90 for each inpatient stay.  
 
The file shows that you spent 1 day in an inpatient unit. Therefore, you have been asked to pay $225 per day 
for the first day of inpatient hospital services. The inpatient hospital services 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 inpatient hospital services 
provided from September 4, 2021, to September 5, 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 from 
November 22, 2021, to November 24, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you should have met 
your MOOP for the year and not of been charged a copayment. The Plan denied your request. The Plan says 
the enrollee met there MOOP after this claim and the proper copayment was paid. 
 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 $6,700 
maximum-out-of-pocket (MOOP) for copayments and coinsurance for in-network covered services once you 
reach your MOOP you will not have to pay any out-of-pocket costs for the rest of the year and a $325 
copayment for per day for days 1 - 6, then $0 copayment after day 6. Prior to the dates of service, the MOOP 
paid was $6,050. The copayment amount of $650 was charged for the inpatient stay for the dates of service 
which then the enrollee hit their MOOP of $6,700 ($6,050 MOOP prior + $650 copayment). 
 
You have been asked to pay a $650 copayment for an inpatient hospital stay. 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 22, 2021, to November 24, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement of the copayment for the 
esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple (43239) and the diagnostic 
colonoscopy (45378) provided on June 28, 2021. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
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 $200 
copayment for Medicare-covered outpatient hospital facility visits.  
 
 You have been asked to pay a $200 copayment for the Medicare-covered outpatient hospital facility visit for 
outpatient surgery provided. 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 issue reimbursement of the copayment for the 
esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple (43239) and the diagnostic 
colonoscopy (45378) provided on June 28, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit (99283) provided 
on September 17, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service 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 $90 
copayment for each emergency room visit.  
 
You have been asked to pay a $90 copayment for the emergency room visit provided. 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 emergency room visit (99283) provided on 
September 17, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit (99283) provided 
on September 3, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service 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 $90 
copayment for emergency care services.  
 
You have been asked to pay a $90 copayment for the emergency care service provided. 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 emergency room visit (99283) provided on 
September 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography, of the upper 
extremity; without contrast material (73200) provided on November 12, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service 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 $110 
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic). 
 You have been asked to pay a $95.38 copayment for the Medicare-covered radiological diagnostic service 
provided. This is the Plans allowed amount for this service which is less than the applicable copayment. 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 computed tomography, of the upper extremity; without 
contrast material (73200) provided on November 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hearing aids provided on July 17, 2021. 
 
You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says there is 
no coverage if hearing aids, or related services are received from an out-of-network provider. The hearing 
benefit is not covered if the services are not registered in advance. 
 
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 ordered through the Plans hearing provider. 
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plans 
hearing provider. 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 reimburse you for hearing aids 
provided on July 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a leuprolide acetate injection provided on 
May 13, 2021. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you received the bill 7 months after 
the procedure and you should not be held responsible. 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 20% 
coinsurance for Part B drugs, including chemotherapy drugs.  
 
You have been asked to pay $122.04, which is 20% of the allowed amount for the injection ($612.21 allowed 
amount x 20% coinsurance = $122.44). The injection 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 leuprolide acetate injection 
provided on May 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services provided on September 25, 
2021. 
 
You asked the Plan to pay for the paramedic intercept services. 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 on September 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical connection between the wheelchair 
controller and two or more motors (E2311), expandable controller (E2377) and harness (E2313). 
 
You asked the Plan to pre-approve an electrical connection between the wheelchair controller and two or more 
motors, expandable controller, and harness. You say that the items 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 wheelchair accessories 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 an electrical connection between the 
wheelchair controller and two or more motors, expandable controller, and harness. Our reviewer says that the 
items are not medically necessary. Our physician reviewer found based on the medical records provided there 
is no documentation that the enrollee meets the coverage criteria detailed in the Local Coverage Article: 
Wheelchair Options/Accessories - Policy Article - A52504 for the requested accessories. Provided records 
document that the enrollee has 3-/5 to 3+/5 upper extremity strength with no reported limitations with regard to 
self-feeding. Medical records do not clearly indicate that the enrollee has inadequate upper extremity strength 
and function to operate the wheelchairs power options with their own switches. 
 
 
 
 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electrical connection between the wheelchair controller and two or more 
motors, expandable controller, and harness have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an electrical connection between the wheelchair controller and two or more motors 
(E2311), expandable controller (E2377) and harness (E2313).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on October 4, 2021. 
 
You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 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 October 3, 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 laboratory services 
provided on October 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthotic device to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a MyoPro orthotic device to be provided by an OON provider. 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 MyoPro orthotic device to be 
provided by an OON provider. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the MyoPro is not known to be 
effective, based on scientific evidence, professional standards and expert opinion, in improving health 
outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is 
insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this 
enrollee, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the 
literature that this device will increase participation in bimanual activities. 
 
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 MyoPro orthotic device to be provided by an OON provider have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro orthotic device to be provided 
by an out-of-network (OON) provider.