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

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on October 
25, 2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 $120 copayment for outpatient surgery.  
 
The enrollee has been asked to pay a $120 copayment for an outpatient surgery. This item/service falls within 
the outpatient surgery 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 an 
outpatient surgery provided on October 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an office visit and an electrocardiogram 
(ECG) provided on May 12, 2022. 
 
You asked the Plan to waive the cost share for an office visit and an ECG. You say that you disagree with the 
cost share. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1000 deductible which applies to out-of-network 
physician/practitioner service and out-of-network outpatient diagnostic test. You are being asked to pay 
$162.74 towards the deductible. The item or service you asked the Plan to waive the cost share for falls within 
the out-of-network physician/practitioner service and out-of-network outpatient diagnostic test benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 
deductible which applies to out-of-network physician/practitioner service and out-of-network outpatient 
diagnostic test. This cost sharing is a contractual obligation that had not been met at the time an office visit and 
an ECG was received on May 12, 2022. Therefore, we decided that the Plan does not have to waive the cost 
share for an office visit and an electrocardiogram (ECG) provided on May 12, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve treatment with Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says that step-therapy rules for coverage of the requested drug 
have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the 
requested drug is medically reasonable and necessary in this case. Our physician reviewer found that the Plan 
requires a trial of an oral bisphosphonate and of zoledronic acid before they will approve the requested drug. 
The enrollee has not tried and failed treatment with zoledronic acid. However, the use of an oral 
bisphosphonate and of zoledronic acid have the potential to have adverse effects in this case. There is strong 
evidence supporting drug holidays for most patients after three to five years of continuous bisphosphonate 
therapy. Due to the potential for rare adverse events associated with long-term use (atypical femoral fractures 
as well as osteonecrosis of the jaw), a drug holiday is recommended for most patients after long-term 
bisphosphonate therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have been met. Therefore, we decided that the Plan has to pre-approve 
treatment with Prolia (J0897).  
 
  If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an office visit and podiatry exam provided 
on August 25, 2022, to September 26, 2022. 
 
You asked the Plan to waive the cost share for an office visit and podiatry exam. You say that this should be 
covered. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $400 deductible which applies to Podiatry Services.  
 
The item or service you asked the Plan to waive the cost share for falls within the Podiatry Services benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $400 
deductible which applies to Podiatry Services. This cost sharing is a contractual obligation that had not been 
met at the time an office visit and podiatry exam was received on August 25, 2022 to September 26, 2022. 
Therefore, we decided that the Plan does not have to waive the cost share for an office visit and podiatry exam 
provided on August 25, 2022, to September 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) 
provided on November 09, 2022. 
 
You asked the Plan to waive the copayment for magnetic resonance imaging (MRI). You say that you cannot 
afford this charge. The Plan denied your request. The Plan says this cost sharing was charged 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 a $180 
copayment for advanced imaging services. 
 
You have been asked to pay a $180 copayment for magnetic resonance imaging (MRI). This item/service falls 
within the advanced imaging 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 
magnetic resonance imaging (MRI) provided on November 09, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
on June 10, 2022, to July 03, 2022. 
 
You asked the Plan to waive the copayment for skilled nursing facility (SNF) care. You say that you were told 
there would be no charge for this. The Plan denied your request. The Plan says this cost sharing was charged 
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 a $188 
copayment for skilled nursing facility (SNF) care. 
 
You have been asked to pay a $188 copayment for skilled nursing facility (SNF) care. This item/service falls 
within the skilled nursing facility (SNF) 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. You have been asked to pay $564 ($188 x 3 days) for your SNF care. 
Therefore, we decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) 
care provided on June 10, 2022, to July 03, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out-of-network durable medical 
equipment (DME) provided on September 14, 2022. 
 
You asked the Plan to waive the coinsurance for out-of-network DME. You say that you disagree with the 
coinsurance. The Plan denied your request. The Plan says this cost sharing was charged 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 a 30% 
coinsurance for out-of-network durable medical equipment (DME).  
 
You have been asked to pay a 30% coinsurance for out-of-network DME. The total allowed amount for the 
DME is $1,520 ($1,520 x 30% = $456). However, you are being asked to pay $314.56 which is less than the 
required amount. This item/service falls within the out-of-network durable medical equipment (DME) 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 out-of-network durable medical equipment 
(DME) provided on September 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Prosthetic devices and supplies provided 
on September 14, 2022. 
 
You asked the Plan to waive the coinsurance for Prosthetic devices and supplies. You say that this should be 
covered. The Plan denied your request. The Plan says this cost sharing was charged 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 20% 
coinsurance for prosthetic devices and related supplies. 
 
You have been asked to pay 20% coinsurance for Prosthetic devices and supplies. This item/service falls within 
the prosthetic devices 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 Prosthetic devices and supplies provided on September 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive metabolic panel lab provided on September 
02, 2022. 
 
You asked the Plan to pay for comprehensive metabolic panel lab. You say that this was medically necessary 
and should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for comprehensive 
metabolic panel lab provided on September 02, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for outpatient diagnostic tests, outpatient 
hospital services and outpatient rehabilitation services provided on May 25, 2022, to September 20, 2022. 
 
You asked the Plan to waive the cost share for outpatient diagnostic tests, outpatient hospital services and 
outpatient rehabilitation services. You say that you disagree with the cost share. The Plan denied your request. 
The Plan says this cost sharing was charged 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 a 10% 
coinsurance for outpatient diagnostic tests a $250 copayment for outpatient hospital services and a $30 copayment per visit for outpatient rehabilitation services.  
 
You have been asked to pay a 10% coinsurance outpatient diagnostic tests, a $250 copayment for outpatient 
hospital services and a $30 copayment per visit for outpatient rehabilitation services. The total allowed amount 
for the diagnostic test is $373. You are being asked to pay $37.30 for the diagnostic test ($373 x 10% = 
$37.30). For outpatient rehab you are being asked to pay $240 ($30 x 8 visits = $240). The total amount you 
are being asked to pay for all services is $527.30 ($37.30 + $250 + $240 = $527.30). This item/service falls 
within the outpatient diagnostic tests, outpatient hospital services and outpatient rehabilitation 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 cost share for outpatient diagnostic tests, outpatient hospital 
services and outpatient rehabilitation services provided on May 25, 2022, to September 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a therapy office visit provided on July 02, 2021. 
 
You asked the Plan to pay for a therapy office visit. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a therapy office visit 
provided on July 02, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99203 provided on April 25, 2022. 
 
You asked the Plan to pay for procedure code 99203. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that a valid interim rate needs to be submitted. 
 
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. 
 
We looked at the file and the rules. The Plan denied services requiring an interim rate. However, the 
documentation provided does not indicate that the provider is a newly certified rural health clinic. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. Therefore, we decided that the Plan has to pay for procedure code 99203 provided on April 
25, 2022.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve INR blood draws to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the blood draws. You say that the services are medically necessary. The 
Plan denied your request. The Plan says network providers are available to provide necessary care. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
INR blood draws to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on July 12, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the copayment. 
The Plan denied your request. The Plan says this cost sharing was charged 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 a $50 
copayment for outpatient diagnostic tests/including ultrasounds.  
 
You have been asked to pay a $50 copayment for an ultrasound. This item/service falls within the outpatient 
diagnostic tests/including ultrasounds benefits 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 ultrasound provided on July 12, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on October 4, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you 
disagree with the denial and would like the Plan to reconsider. The Plan denied your request. The Plan says 
these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 4, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on October 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete denture on tooth #24 and #25 (D5520) on 
September 14, 2022. 
 
You asked the Plan to pay for the complete denture on tooth #24 and #25 (D5520). You say that this was a 
comprehensive dental service and should be covered with a 50% coinsurance. The Plan denied your request. 
The Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the complete denture on tooth #24 and 
#25 (D5520) are not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pay for the complete denture on tooth #24 and #25 (D5520) on September 14, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a laboratory test provided on January 19, 2022. 
 
You asked the Plan to pay for the laboratory test. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a laboratory test provided on January 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 15, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the genetic testing 
provided on August 15, 2022.