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

 
We decided that the Plan does not have to waive the cost share for inpatient hospital care provided on October 
2, 2022, to October 5, 2022 
 
You asked the Plan to waive the cost share for inpatient hospital care. 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 inpatient hospital care.  
 
You have been asked to pay a 10% coinsurance for inpatient hospital care. The allowed amount for the 
inpatient care is $13,817.43. However, you are being asking to pay $841.26 when you hit your $1,050 out-of-
pocket maximum. This item/service 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 cost share for inpatient hospital care provided on October 2, 2022, to October 5, 
2022
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the hyaluronan injection provided on 
October 12, 2021. You asked the Plan to waive the coinsurance for the injection. You say that the provider's office is billing you 
for $1,984.77. 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 Medicare Part B drugs.  
 
You have been asked to pay $215.81, which is 20% coinsurance of the allowed amount for the injection. This 
item/service falls within the Medicare Part B 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.  
 
Specifically, the record indicates that the Plan has paid the Medicare allowed amount for this service. A 
Medicare provider should accept the Medicare allowed amount as payment in full. In this case, the Plan is not 
responsible for paying the balance that remains after the Medicare allowed payment. Therefore, we decided 
that the Plan does not have to pay more for the hyaluronan injection provided on October 12, 2021.  
 
Please note that neither you nor the Plan are responsible for paying the balance bill. Please contact the 
provider about a refund for any amount you paid above the Medicare allowable amount for the injection. If the 
provider is billing you for charges beyond any applicable cost-sharing amounts, please contact the Plan 
directly.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the radiology and outpatient hospital 
services provided from November 8, 2022, to December 21, 2022. 
 
You asked the Plan to waive the copayment for the radiology and outpatient hospital services. You say that you 
should not be billed multiple copayments for visits that were continuations of a prior surgery. The Plan denied 
your request. The Plan says the cost sharing will be applied according to the Plan contract. 
 
 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 $100 
copayment for outpatient x-ray services.  
 
You have been asked to pay a $925 copayment for the radiology and outpatient hospital services. This total 
includes a $100 copayment for an x-ray, a $225 copayment for a CT scan and a $600 copayment for outpatient 
hospital services ($300 per visit x 2 visits = $600). The x-ray and CT scan fall within the outpatient diagnostic 
tests benefit category. The outpatient hospital services fall within the outpatient hospital services 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 radiology and outpatient hospital services provided from 
November 8, 2022, to December 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the injection provided on August 04, 2022. 
 
You asked the Plan to waive the copayment for the injection. You say that you did not have a copayment for 
this service 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). Your contract with the Plan clearly says that you must pay a $300 
copayment for outpatient surgery, including services provided at ambulatory surgical centers. 
 
You have been asked to pay a $300 copayment for the injection. This item/service falls within the outpatient 
surgery, including services provided at 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 injection provided on August 04, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan of the brain. 
 
You asked the Plan to pre-approve a PET scan of the brain. You say that the enrollee suffers from dementia and 
are needs a PET scan to help with possible treatment. The Plan denied your request. The Plan says a PET scan 
of the brain is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that this imaging is promising to exclude 
Alzheimers disease and to enrich clinical trails seeking better treatments or prevention strategies for 
Alzheimers disease. In this case the enrollee would not be receiving the requested PET scan as part of a 
clinical study and the request would not meet Medicare criteria for coverage at this time. 
   
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan of the brain.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit provided 
on January 10, 2023, to January 31, 2023. 
 
You asked the Plan to waive the copayment for each physical therapy (PT) visit. You say that services should 
be covered with $0 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 $40 
copayment for outpatient rehabilitation service. 
 
You have been asked to pay a $40 copayment for each physical therapy (PT) visit. This item/service falls 
within the outpatient rehabilitation service 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. The total you owe is $240 ($40 per visit x 6 visits = $240) Therefore, we 
decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit provided on 
January 10, 2023, to January 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each ferric carboxymaltos injection 
provided on November 08, 2022, to November 15, 2022. 
 
You asked the Plan to waive the coinsurance for each ferric carboxymaltos injection. You say that you have 
never had charges like this for these injections and need to have the charges explained. 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 Medicare Part B drugs. 
 
You have been asked to pay 20% coinsurance for each ferric carboxymaltos injection. This item/service falls 
within the Medicare Part B 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 
each ferric carboxymaltos injection provided on November 08, 2022, to November 15, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary so you can control 
your sugar levels. The Plan denied your request. The Plan says that the Medicare criteria was not met. 
 
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. Specifically, the Plan did not collect medical records from their participating 
provider who ordered the requested CGM. Participating providers are considered agents of the Plan. Without 
this necessary documentation we are unable to make a determination as to whether the enrollee has met the 
criteria for coverage of a CGM. Phone call logs regarding particulars of an enrollee's condition and a prior 
authorization are not an acceptable substitution for medical records. Therefore, we decided that the Plan has to 
pre-approve a continuous glucose monitor (CGM).  
 
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 pay for a Covid-19 test provided on October 14, 2021. 
 You asked the Plan to pay for a Covid-19 test. You say that the enrollee lives in an assisted living facility 
where it is required for them to be tested. You say that the services are not hospice related. The Plan denied 
your request. The Plan says Original Medicare is responsible for payment. 
 
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 Covid-19 test provided on October 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on 
November 01, 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). Your contract with the Plan clearly says that you must pay a $350 
copayment for outpatient surgery/hospital outpatient facility. 
 
You have been asked to pay a $350 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/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 an outpatient surgery provided on November 01, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on September 14, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the records attached support the services 
provided. 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 laboratory services 
provided on September 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
July 22, 2022, to July 24, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you think this 
copayment is too high. 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 $350 copayment per day for days 1-5 of each inpatient hospital stay.  
 The enrollee has been asked to pay a $350 copayment per day for days 1-2 of the inpatient hospital stay. You 
have not been charged for the day you were discharged. You have been asked to pay a total of $700 ($350 
copayment per day x 2 days = $700). These items/services fall within the inpatient hospital care 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 inpatient hospital stay 
provided from July 22, 2022, to July 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve combination use of Keytruda, Oxaliplatin, Irinotecan, 
Fluorouracil, Leucovorin, Palonosetron, Udenyca, Dexamethasone, and Fosaprepitant. 
 
You asked the Plan to pre-approve drug combination. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 drug combination. Our reviewer says 
that the enrollee does not meet criteria for this drug combination. Our physician reviewer found the requested 
combination is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. This combination is not supported by one of the major drug compendia or by clinical research appearing in a Medicare-approved 
medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of drug combination have not been met. Therefore, we decided that the Plan does 
not have to pre-approve combination use of Keytruda, Oxaliplatin, Irinotecan, Fluorouracil, Leucovorin, 
Palonosetron, Udenyca, Dexamethasone, and Fosaprepitant.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. We looked at the file and Medicare rules. The documentation does not indicate that the enrollee uses insulin 
with at least three daily injections or requires frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the requested 
device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture - cast metal framework 
with resin denture bases (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you lost your partial and you need a 
replacement. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested service was exhausted on date of service March 4, 2022.  Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture - cast metal 
framework with resin denture bases (D5214).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 64494. We decided that the Plan does not have to pay for S0020.   
You asked the Plan to pay for injection services (procedure codes 64494 and S0020) rendered on May 10, 
2022.. You say that this should be paid for. The Plan says that the records do not support the services billed. 
 
We decided that the Plan has to pay for 64494.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. The definition of CPT 64494 is 
"Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating 
that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition 
to code for primary procedure)." 
 
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 for CPT 64494. Our reviewer says that the enrollee had 
low back pain and received diagnostic right facet joint blocks at two levels on May 10, 2022. This procedure 
was billed under CPT 64494. The procedure details this procedure completely. The coding was accurate. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
64494.  
 
We also decided that the Plan does not have to pay for S0020. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. The definition of Healthcare Common 
Procedure Coding System (HCPCS) S0020 is "Injection, bupivicaine hydrochloride, 30 ml." 
 
We find that procedure code S0020 has a Status Indicator of I on the Physician Fee Schedule. This means that 
this procedure code is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for S0020. 
 
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.