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

 
We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 Ozempic.  
 
Benefits for these services 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the chemodenervation provided on 
December 15, 2021. 
 
You asked the Plan to waive the copayment for chemodenervation. You say that the cost of this ongoing 
treatment is a financial hardship. 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 $250 
copayment for each outpatient hospital visit.  
 
You have been asked to pay $250 copayment for chemodenervation. Chemodenervation falls within the 
Outpatient surgery, including services provided at hospital 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 waive the copayment for the chemodenervation provided on December 
15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist visit on November 29, 2021. 
 
You asked the Plan to waive the copayment for specialist visit. You say that you did not know the doctor was a 
specialist. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $30 copayment for provider and professional services at an in-network specialists office.  
 
The enrollee has been asked to pay $30 copayment for specialist visit. Specialist visits fall within the 
Physician/Practitioner services, including doctor's office visits 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 the specialist visit on November 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty walker (E0149, E0156). 
 
You asked the Plan to pre-approve the heavy-duty walker. You say that the walker is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy-duty walker is covered for patients over 
300lbs. 
 
We looked at the file and Medicare rules. The record shows that the enrollee is 244lbs, less than the 300lbs 
required to meet coverage criteria for a heavy-duty walker. Based on this information, we decided that 
Medicare rules for coverage of the heavy-duty walker have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a heavy-duty walker (E0149, E0156).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Imaging services provided on November 17, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Imaging services. You say that the services provided were medically necessary. 
The Plan denied your request. The Plan says The request is not medically necessary under Medicare rules 
because you have not yet had an esophagogastroduodenoscopy EGD to determine 
an abnormality and this procedure was performed despite receiving a denial on pre-service review. 
 
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 Imaging services provided on November 17, 2021 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cataract surgery provided on November 18, 
2021 and December 2, 2021. 
 
You asked the Plan to waive the copayment for cataract surgery. You say that you were over charged for your 
cataract surgery and would like to be reimbursed for $234.06. The Plan denied your request. The Plan says the 
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 $245 
copayment for outpatient surgery in an in-network surgical center.  
 
  You have been asked to pay a total of $490 for cataract surgery ($245/surgery x 2 surgeries = $490). The 
cataract surgery 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. Contact the Plan regarding information on any additional charges. Therefore, we 
decided that the Plan does not have to waive the copayment for cataract surgery provided on November 18, 
2021 and December 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network 
(OON) provider on December 11, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider on 
December 11, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit (99285) 
provided from December 7, 2021, to December 8, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on 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 $90 
copayment for Emergency care.  
 
 
  You have been asked to pay a $90 copayment for an ER visit. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for an emergency room (ER) visit (99285) provided from December 7, 2021, to December 8, 2021.
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 these services are medically necessary. 
The Plan denied your request. The Plan says that your medical needs are being met in the current acute setting. 
 
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. You appear 
to be more stable and improving and should only require short-term additional acute care services, including 
additional weaning, that can safely be completed at the current facility until more stable and appropriate for a 
lower level of care. You do not require services at the LTACH that are not already available at the current 
facility. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH 
services. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the EEG, CT scan and OT received from 
December 16, 2021, to December 17, 2021. 
 
You asked the Plan to waive the copayment for the EEG, CT scan and OT. You say that you would like these 
services covered. 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 $75 
copayment for the EEG, a $180 copayment for the CT scan and a $40 copayment for the OT. 
 
You have been asked to pay a total of $230 for the EEG, CT scan and OT.  
 
Date of Service Service Standard Copayment Member Liability 
December 16, 2021 CT Scan $180 $155 
December 17, 2021 EEG $75 $35 
December 17, 2021 OT $40 $40 
TOTAL:   $230 
 
The EEG and CT scan fall within the Outpatient diagnostic tests and therapeutic services and supplies benefit 
category. The OT falls within the 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 copayment for the EEG, CT scan and OT received from December 16, 2021, to 
December 17, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on December 30, 
2021. 
 
You asked the Plan to waive the copayment for ultrasound. You say that the plan should pay for the medically 
necessary procedure. 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 $160 
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 $144.04, which is less than the standard $160 copayment for an ultrasound. 
Ultrasounds fall 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 the ultrasound provided on December 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (83520, 82656, 89055, 87177, 87209) provided 
January 8, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (83520, 82656, 89055, 87177, 87209) provided January 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
January 4, 2022 to January 10, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the hospital stay was 
less than six days. The Plan denied your request. The Plan says the hospital stay was six days and the 
copayment amount charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment per day for days 1 through 6 per benefit period.  
 
 
 You have been asked to pay a total of $1,650 for the inpatient hospital stay (6 days x $275 copayment = 
$1,650). 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 the inpatient hospital stay provided on January 4, 2022 to January 10, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on December 12, 2021, by 
an OON provider. 
 
You asked the Plan to pay for the outpatient services. You say that it was medically necessary to treat the 
enrollee and you would like the claim to be reprocessed for payment. The Plan denied your request. The Plan 
says the rendering provider is an OON 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 the outpatient services provided on December 12, 
2021, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (K0004 and E2624) provided 
on September 1, 2021. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for the durable medical equipment (K0004 and E2624) provided on September 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient cardiac catheterization 
service (93458) provided on December 13, 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 $475 
copayment for outpatient hospital services.  
 
 
 You have been asked to pay a $475 copayment for the outpatient hospital 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 outpatient cardiac catheterization service (93458) provided on 
December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit on December 16, 2021. 
 
You asked the Plan to waive the deductible for an office visit. You say that your plan fully covers an annual 
physical exam. The Plan denied your request. The Plan says the service is a covered benefit, but the member's 
deductible hadn't been met at the time of the date of service. 
 
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 $110 
deductible for an office visit. There is a list in the EOC of services that will not have a deductible apply and 
primary care physician office visit services are not on the list. The allowed amount of the claim is $98.33 and is 
the total cost share amount owed. 
 
You have been asked to pay $110 deductible for an office visit. An office visit falls within the 
Physician/Practitioner Services, Including Doctors Office Visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the deductible for an office visit on December 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for unlisted ambulance service provided on 
December 25, 2021. 
 
You asked the Plan to waive the copayment for unlisted ambulance service. You say that you believe this claim 
should be appealed because you did not call the ambulance service, and when they arrived there was nothing 
wrong with you. You also say they took your blood pressure, and it was slightly low. You also say that you 
believe the volunteer company should not charge you. The Plan denied your request. The Plan says you were 
charged the correct the 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 $250 
copayment for each Medicare-covered services or one-way trip by ground transportation.    
You have been asked to pay a $250 copayment for each Medicare-covered services or one-way trip by ground 
transportation. for unlisted ambulance service. unlisted ambulance service falls within the ambulance services 
benefit category. The record shows that you were seen by this provider. 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 unlisted ambulance service provided on December 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the MRI and anesthetic injection provided 
on August 9, 2021, and October 5, 2021. 
 
You asked the Plan to waive the copayment for the MRI and anesthetic injection. You say that the services 
should be covered. 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 $90 
copayment for the MRI and a $295 copayment for the anesthetic injection. 
 
You have been asked to pay a total of $385 for the MRI and anesthetic injection. An MRI falls within the 
Other outpatient diagnostic tests - Radiological diagnostic services, not including x-rays benefit category. 
The anesthetic injection falls within the Outpatient Surgery and Other Medical 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 waive 
the copayment for the MRI and anesthetic injection provided on August 9, 2021, and October 5, 2021.