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

 
We decided that the Plan does not have to waive the copayment for the specialist services provided on August 
16, 2021, to September 01, 2021. 
 
You asked the Plan to waive the copayment for the specialist services. You say that you had already met your 
out-of-pocket maximum for the year. 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 $105 
copayment for provider and professional services (specialist). 
 
You have been asked to pay a $105 copayment for the specialist services. This item/service falls within the 
provider and professional services (specialist) 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. Per the EOC, there is a $35 copayment for specialist services. The file 
shows 3 visits, for a total of $105. Please note that cost sharing is applied to the out-of-pocket maximum in the order the claims are processed by the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for the specialist services provided on August 16, 2021, to September 01, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-alignable system for the enrollee. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says this request cannot be used with this preparatory prosthesis. 
 
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 the system. Our reviewer says that the 
requested system is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided records do not document how the alignable system is reasonable and necessary for a 
non-alignable preparatory prosthesis.  
 
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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a non-alignable system for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the home infusion services provided on June 21, 2022. 
 
You asked the Plan to pay for the home infusion services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that a corrected claim is needed. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has denied payment for the services provided stating a 
corrected claim is needed. However, the Plan has provided no explanation why the submitted claim is invalid 
for payment based on Medicare guidelines. We find that the Plan has not provided enough evidence to support 
their reasoning for the denial of payment. Therefore, we decided that the Plan has to pay for the home infusion 
services provided on June 21, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for tomographic myocardial perfusion imaging 
provided on June 14, 2022. 
 
You asked the Plan to waive the copayment for tomographic myocardial perfusion imaging. You say that if you 
had known how much the copay was, you would not have had it done. 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 $325 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $325 copayment for tomographic myocardial perfusion imaging. This 
item/service 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 tomographic myocardial perfusion imaging provided on 
June 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services provided to the enrollee was medically 
necessary and you would like the claim paid. The Plan denied your request. The Plan says that the rendering 
and referring providers are both OON providers and there was no 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 an office visit provided on July 28, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for nail trimming services provided to the 
enrollee from January 17, 2022, to March 21, 2022. 
 
You asked the Plan to reduce the copayments for the nail trimming services. You say that the enrollee only 
paid $10 for these services before. 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 $35 copayment for podiatry services.  
 
The enrollee has been asked to pay $28.37 for each of the nail trimming services, which is less than the $35 
copayment per the EOC. The total for both visits is $56.74. This item/service falls within the podiatry 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 reduce the copayments for nail trimming services 
provided to the enrollee from January 17, 2022, to March 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Part B drugs on January 26, 2022. 
 
You asked the Plan to waive the coinsurance for Part B drugs. You say that you want to appeal the amount 
being charged. 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 20% 
coinsurance for Medicare-covered Part B medications, including, but not limited to, chemotherapy and drugs 
used during outpatient diagnostic procedures. These drugs are covered under Part B of Original Medicare. 
Members of our plan receive coverage for these drugs through our plan. Covered drugs include drugs that 
usually arent self-administered by the patient and are injected or infused while you are getting physician, 
hospital outpatient, or ambulatory surgical center services. The provider billed in the amount of $268 and the 
allowed amount is $133.74. $133.74 x 20% = $26.75. The provider also billed in the amount of $7,826 and the 
allowed amount is $2,038.63. $2,038.63 x 20% = $407.73. $26.75 + $407.73 = $434.48. Therefore, results in 
the total cost sharing amount of $434.48. 
 You have been asked to pay a 20% coinsurance for Part B drugs. This item/service falls within the Medicare 
Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for Part B 
drugs on January 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 28, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy visits provided on June 15, 
2021. 
 
You asked the Plan to waive the coinsurance for chemotherapy visits. You say that you cannot afford this large 
cost share as you are on a restricted income. 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 20% 
coinsurance for Medicare Part B prescription drugs. Your maximum out of pocket (MOOP) amount is $4300. 
Because you had not yet met that amount, these cost shares are correct. 
$1.261.29 x 20% = $252.26 + $315.32 x 20% = $63.06 + $216.22 x20% = $43.24 + $92.66 x 20% = $18.53. 
$252.26+$63.06+$43.24+$18.53+1215.29= $1,592.38 
$1,592.38 - $200 = $1392.38 
 
You have been asked to pay a $1392.38 coinsurance for chemotherapy visits. This item/service falls within the 
Medicare Part B prescription drugs benefit category.  This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for chemotherapy visits provided on June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on April 14, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. 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 $15 
copayment for services obtained from a primary care provider or under certain circumstances, treatment by a 
nurse practitioner or physicians assistant or other non-physician health care professionals in a primary care 
providers office (as permitted under Medicare rules). Covered services include medically-necessary medical or 
surgical services furnished in a physicians office. 
 
 
 
 You have been asked to pay a $15 copayment for office visit. This item/service 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 office visit on April 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the CTA. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the requested provider is not a network provider, and prior authorization for 
services was not obtained. 
 
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 
a computed tomographic angiography (CTA) to be provided 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 the pacemaker replacement procedure 
provided on May 23, 2022. 
 
You asked the Plan to waive the copayment for the pacemaker replacement procedure. You say that you were 
informed there was no copayment for the procedure. 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 $350 
copayment for outpatient surgery in an ambulatory surgical center or hospital outpatient facility. 
 
You have been asked to pay a $350 copayment for the pacemaker replacement procedure. This item/service 
falls within the outpatient surgery in an ambulatory surgical center or hospital outpatient facility 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 pacemaker replacement procedure provided 
on May 23, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve power wheelchair repairs. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that a 
power wheelchair is not appropriate. 
 
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 file shows that the Plan has instead approved a manual wheelchair, 
instead of repairing the power wheelchair, based on a physiatry exam. This exam was not included in the case 
file. A request was sent to the Plan for additional records. However, the returned records again did not include 
the requested physiatry exam. The medical records provided show that you are an incomplete quadriplegic. 
There are insufficient medical records to show that you are able to self-propel a manual wheelchair. 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 pre-approve power wheelchair repairs.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an out-of-network hospital observation 
provided on March 25, 2022. 
 
You asked the Plan to waive the copayment for an out-of-network hospital observation. You say that you 
received a bill and want any help you can get with it. 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 20% 
coinsurance for outpatient hospital observation. The allowed amount of this item or service was $94.23, 
resulting in a coinsurance of $18.85 ($94.23 x 20% = $18.85). 
 
You have been asked to pay a $18.85 coinsurance for an out-of-network hospital observation. This item/service 
falls within the outpatient hospital observation benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for an out-of-network hospital observation provided on March 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on May 10, 2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that they didnt even do anything, 
they just looked at you and billed the plan. 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 $40 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for a specialist visit. This item/service 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 copayment for a specialist visit provided on May 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for chest x-ray provided on June 22, 2022. 
 
You asked the Plan to waive the copayment for chest x-ray. You say that you should not be responsible to pay 
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 $30 
copayment for x-ray. 
 
You have been asked to pay a $30 copayment for chest x-ray. This item/service falls within the x-ray 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 chest x-ray provided on June 22, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on February 9, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has denied payment for the testing in question because they 
state they reached out to the providers office and confirmed that testing was not ordered. This stands in 
opposition to the signed order form and medical records that were submitted. The Plans submitted evidence 
that testing was not ordered is not supported in this case. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on February 9, 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.