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

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay from August 7, 
2021, to August 13, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you are not used to 
getting copays this high. 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 a $360 
copayment per day for each Medicare-covered inpatient hospital stay.  
 
 
 You have been asked to pay a $1,800 copayment ($360 x 5 days) 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 from August 7, 2021, to August 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on November 
29, 2021. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you feel the copayment 
amount is exorbitant for the services provided. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment for each ambulance service, including evaluation, treatment, or transportation.  
 
You have been asked to pay a $225 copayment for the ambulance services. The ambulance services fall within the Ambulance 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 ambulance 
services provided on November 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laryngoscopy provided on October 19, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laryngoscopy. You say that you would like to appeal the denial of the claim. The 
Plan denied your request. The Plan says prior authorization is required for an out-of-network office visit. 
 
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 laryngoscopy provided on October 19, 2021 by an 
out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on December 
3, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that your husband was discharged 
from the hospital too soon after having surgery. You also say you will not be financially responsible for costs 
related to this incident. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $250 copayment for per trip for ambulance services.  The enrollee has been asked to pay a $250 copayment for ambulance services. Ambulance services falls within 
the Ambulance Services benefit category. This means that the enrollee has been asked to pay the correct 
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to 
pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
ambulance services provided on December 3, 2021.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor and supplies for the 
enrollee. 
 
You asked the Plan to pre-approve a continuous glucose monitor and supplies. You say that a continuous 
glucose monitor and supplies is medically necessary. The Plan denied your request. The Plan says all of the 
required coverage criteria for a a continuous glucose monitor and supplies are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of a continuous glucose monitor and supplies have 
not been met. Medicare does not allow exceptions to these criteria. Therefore, we decided that the Plan does 
not have to pre-approve a continuous glucose monitor and supplies for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (99213) provided on 
November 9, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you are being charged for 
a facility fee, which is your first encounter, since you are a frequent member of 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 refer to the 
cost sharing guide for cost sharing amounts for specialist visits. Your contract with the Plan also clearly says 
that you must pay a $30 copayment per visit for specialist in office/telehealth.   
You have been asked to pay a $30 copayment for a specialist office visit. A specialist office visit falls within 
the physician/practitioner services, including doctor's office visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a specialist office visit (99213) provided on November 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis tablets. 
 
You asked the Plan to pre-approve Eliquis. You say that Eliquis is medically necessary. The Plan denied your 
request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis tablets.  
 
Benefits for Eliquis 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit provided on January 4, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary visit. You say that on pages 39 to 40 of the Plan's 2022 
 The Plan denied your request. The Plan says authorization should be on file, and you do not discriminate as the 
services were rendered in good faith. 
 
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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the domiciliary visit provided on January 4, 2022, by an out-of-
network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for reduction mammoplasty provided on 
October 13, 2021. 
 
You asked the Plan to reduce the copayment for reduction mammoplasty. You say that the surgery was done at 
the ambulatory surgical center not at the hospital. You also say that your copayment should be $325 not $425. 
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 $425 
copayment for outpatient surgery at an outpatient hospital.  
 
According to the Plan, the facility you had your surgery at is not considered a certified ambulatory surgical 
center. Therefore, the copayment applied is correct. You have been asked to pay a $425 copayment for reduction mammoplasty. Reduction mammoplasty 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 reduction mammoplasty provided on October 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
December 4, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you were unaware 
of the ambulance copayment and had no control over it because it was called by someone else. The Plan denied 
your request. The Plan says the proper copayment was applied for the service that was rendered. 
 
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 per trip, each way for ambulance services.  
 
  You have been asked to pay a $250 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance 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 
the ambulance transportation provided on December 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scooter provided from June 30, 2021, to July 30, 2021, 
by an OON provider. 
 
You asked the Plan to pay for the scooter. You say that you got the scooter out of necessity. The Plan denied 
your request. The Plan says the services were provided out-of-network and were not approved in advance. 
 
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 scooter provided from June 30, 2021, to July 
30, 2021, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an arthrocentesis, aspiration and/or injection of the major 
joint or bursa (20611) provided on October 11, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an arthrocentesis, aspiration and/or injection of the major joint or bursa. You say 
that you are appealing with supporting records. The Plan denied your request. The Plan says this provider is 
out-of-network with the Plan, and authorization was not obtained prior to the services being rendered. 
 
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 arthrocentesis, aspiration and/or injection of the 
major joint or bursa (20611) provided on October 11, 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 therapeutic continuous glucose monitor and supplies 
for the enrollee. 
 
You asked the Plan to pre-approve a therapeutic continuous glucose monitor and supplies. You say that a 
therapeutic continuous glucose monitor and supplies are medically necessary for the enrollee. The Plan denied 
your request. The Plan says based on the medical records provided, all of the required coverage criteria are not 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor, and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic 
continuous glucose monitor and supplies for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve calf panel (K0108), 6' footplate outside edge RT 
(K0108), 6' footplate outside edge LT (K0108), and footplate width extension for 11' RT (K0108). 
 
You asked the Plan to pre-approve calf panel, 6' footplate outside edge RT, 6' footplate outside edge LT, and 
footplate width extension for 11' RT. 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 must follow Medicare rules. Medicare rules say that that power wheelchair accessories are covered 
when specific criteria are met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of calf panel, 6' footplate outside edge RT, 6' footplate outside edge LT, and footplate width extension for 11' RT have not been met. Therefore, we decided that the Plan does not have to pre-approve calf panel 
(K0108), 6' footplate outside edge RT (K0108), 6' footplate outside edge LT (K0108), and footplate width 
extension for 11' RT (K0108).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis 5 mg tablet. 
 
You asked the Plan to pre-approve Eliquis. You say that the enrollee does not have transportation to extra 
appointment required with other drugs. The Plan denied your request. The Plan says the requested drug is 
considered 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 Eliquis 5 mg tablet.  
 Benefits for Eliquis 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Injections provided on May 6, 2021 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for Injections. You say that you would like to have the claim processed accordingly. 
The Plan denied your request. The Plan says the provider is OON and authorization was not obtained prior to 
the services being rendered. 
 
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 Injections provided on May 6, 2021 by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for wound care from June 18, 2021 to July 2, 
2021. 
 
You asked the Plan to waive the copayments for wound care. You say that you would like to appeal the 
copayments. The Plan denied your request. The Plan says the copayment was applied to these claims 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $475 copayment for wound care. There were three wound care service dates provided, resulting in a 
total copayment amount of $1,425. The allowed amount of each claim is $419.32, therefore, your total cost-
sharing amount is $1257.96. 
 
The enrollee has been asked to pay a $475 copayment for wound care. wound care falls within the Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit 
category. This means that the enrollee has been asked to pay the correct amount based on the contract with the 
Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for wound care from June 18, 2021 
to July 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cosentyx pens. 
 
You asked the Plan to pre-approve Cosentyx pens. You say that the enrollee suffers from plaque psoriasis and 
has tried and failed multiple aggressive topical steroids. You say that other medications are less effective, and 
the enrollee cannot come in for frequent infusions. The Plan denied your request. The Plan says the requested 
drug is intended for self-administration and the enrollee does not have Part D coverage with the Plan. 
 
  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 Cosentyx pens.