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 January 13, 
2022 to January 18, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you thought you were 
responsible for days 1-3 and you cannot afford to pay this copayment. The Plan denied your request. The Plan 
says copayment 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 $320 
copayment per day, for days 1-5 and a $0 copayment per day for days 6 and beyond. There is a $1600 out-of-
pocket limit for each stay.  
 You have been asked to pay $1600 copayment for the inpatient hospital stay ($320/day x 5 days = $1600). 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 January 13, 2022 to January 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets the Medicare criteria 
for LTACH The Plan denied your request. The Plan says authorization denied because LTACH is not 
medically necessary, and the enrollee is receiving appropriate inpatient acute care until stable enough for 
discharge to a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be more stable and improving and should only require short-
term additional acute care services that can be safely completed at the current facility until more appropriate for 
a lower level of care. The enrollee does not require services at the LTACH that are not already available at the 
current facility.  
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office/outpatient visit (99213) provided on November 5, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office/outpatient visit. You say that this provider regularly complies with all 
administrative requirements for payment. The Plan denied your request. The Plan says the services were billed 
by/rendered by/referred by non-participating providers. The Plan also says that they have also determined that 
these services are not urgent or emergent, nor were they 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 an office/outpatient visit (99213) provided on 
November 5, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breast ultrasound provided on January 10, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you did not know you were going 
to be billed for two procedures. You also say that you were not told that at the time of your test. 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 in-network advanced diagnostic radiology services, including ultrasounds.  
 
You have been asked to pay the allowed amount of $76.01, which is less than the $150 copayment for an 
ultrasound. An ultrasound falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a breast ultrasound provided on 
January 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a segmental pneumatic appliance and a pneumatic 
compressor to be rendered by the out-of-network (OON) provider. 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are in-network providers available to render the 
requested items. 
 
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 at issue in this appeal. We found no exception that would require the Plan 
to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve a segmental 
pneumatic appliance and a pneumatic compressor to be rendered by the out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist telehealth visit provided on December 21, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the specialist telehealth visit. You say that the rendering provider was listed as an 
in-network provider, and you would like the Plan to pay for the bill. The Plan denied your request. The Plan 
says the rendering provider is an out-of-network provider and the enrollee's primary care physician did not 
refer the enrollee to the out-of-network provider. Also, the service rendered was not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a specialist telehealth visit provided on December 
21, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Vision Care provided on November 8, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Vision Care. You say that you would like to request reconsideration for payment. 
The Plan denied your request. The Plan says the provider is out-of-network and it was determined the claim 
was processed correctly. 
 
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 Vision Care provided on November 8, 2021 by an 
out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha Sureclick. 
 
You asked the Plan to pre-approve Repatha Sureclick. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Repatha Sureclick is not covered under the enrollee's 
Medicare Part B 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 Repatha Sureclick.  
 Benefits for Repatha Sureclick 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 a specialist office visit provided on October 21, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the specialist office visit. You say that it is the facilities responsibility to obtain 
authorization and it was medically necessary for the provider to treat the enrollee. The Plan denied your 
request. The Plan says the rendering provider is an out-of-network provider and there was no referral from an 
in-network provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a specialist office visit provided on October 21, 
2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cardiovascular stress test provided on 
October 8, 2021. 
 
You asked the Plan to waive the copayment for a stress test. You say that you have had problems getting billing 
issues resolved with the Plan's customer service. 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 $75-
$300 copayment for diagnostic radiology services, including stress tests.  
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
the allowed amount of $255.04, which is less than the $300 copayment for a stress test. A stress test falls within 
the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a cardiovascular stress test provided on October 8, 2021.  
 
Your complaint about the customer service is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the eye exam and injection provided on 
January 5, 2022. 
 
You asked the Plan to waive the cost share for the eye exam and injection. You say that the 20% coinsurance 
should not apply. The Plan denied your request. The Plan says the cost share was applied correctly. 
 
  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you should pay a $35 
copay for each in-network Medicare-covered eye exam and 20% of the total allowed amount for other 
Medicare-covered Part B drugs and their administration, when in-network.  
 
You have been asked to pay a total of $417.03 for the eye exam, the Part B drug and its administration.   
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
January 5, 2022 Ophthalmic 
Diagnostic Imaging 
(administration) 
$42.01 20% $8.40 
January 5, 2022 Eye Exam $116.49 $35 $35 
January 5, 2022 Part B Drug 
Injection 
$1,868.13 20% $373.63 
TOTAL:    $417.03 
 
The eye exam falls within the Vision care (Medicare Covered) benefit category. The Medicare-Part B drug 
and its administration falls within the Medicare Part B prescription drugs benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the cost share for the eye exam and the injection provided on January 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a Nuclear Stress Test on October 28, 2021. 
 
You asked the Plan to waive the copayment for a Nuclear Stress Test. You say that you cannot afford the 
copayment and that you were not expecting it. 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 $75 
copayment for Nuclear Stress Test.  
 
You have been asked to pay a $75 copayment for a Nuclear Stress Test. A Nuclear Stress Test falls within the 
Outpatient hospital 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 a Nuclear 
Stress Test on October 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the outpatient services provided on January 
7, 2022. 
 
You asked the Plan to waive the deductible for the outpatient services. You say that you feel the cost is too 
high for the injection. The Plan denied your request. The Plan says the proper deductible 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 $750 
deductible which is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered 
services. Once you have paid your deductible, we will begin to pay our share of the costs for covered medical 
services and you will pay your share (your copayment or coinsurance amount) for the rest of the calendar year. 
Prior to the date of service, the total paid towards the annual deductible of $750 was $98.03 leaving a balance 
of $651.97 ($750 annual deductible - $98.03 paid towards deductible). The total amount allowed for the service 
provided was $567.50 which is less than the $651.97 balance on the annual deductible. Therefore, $567.50 was 
charged towards the annual deductible leaving a balance of $84.47 ($651.97 paid towards deductible - $567.50 
charged deductible) to pay before the annual deductible was met. 
 
You have been asked to pay a $567.50 deductible for the outpatient services. The outpatient services deductible 
falls within the What is your plan deductible 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 deductible 
for the outpatient services provided on January 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on January 24, 
2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that the claim should be paid at 100% 
because it was an annual preventative care visit, not an office visit. The Plan denied your request. The Plan 
says the copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for each in-network primary care physician's office visit. 
 
You have been asked to pay $20 for the office visit. An 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 the office visit provided on January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the requested epidural steroid 
injection is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested epidural steroid injection. 
 
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 an epidural steroid injection. Our 
reviewer says that the enrollee does not meet criteria for the requested epidural steroid injection. Our physician 
reviewer found the enrollee has chronic low back pain. She underwent an epidural steroid injection at L4-L5 on 
January 1, 2022, which produced 50-60% pain relief for 3 weeks. The LCD criteria requires 50% pain relief for 
3 months before repeating the injection.  This was not achieved and therefore, the request is considered 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 an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you have pain and pressure on your feet which 
causes you to lose balance. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiation therapy provided from January 
12, 2021, to January 13, 2021. 
 
You asked the Plan to waive the copayment for radiation therapy. You say that these dates of services were on 
Sundays, and you do not receive radiation therapy on Sundays. The Plan denied your request. The Plan says 
you were charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $60 
copayment per provider, per date of service for radiation therapy.  
 You have been asked to pay a $60 copayment for radiation therapy. Radiation therapy falls within the 
outpatient diagnostic tests and therapeutic services and supplies benefit category. The record shows that dates 
of service, January 12, 2021, and January 13, 2021, were not on Sunday. 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 radiation therapy provided from January 12, 2021, to January 13, 2021.