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

 
We decided that the Plan does not have to pre-approve ondansetron tablets. 
 
You asked the Plan to pre-approve ondansetron. You say that you are appealing this denial. The Plan denied 
your request. The Plan says the denial of authorization for this drug is correct, because this drug is not going to 
be used as a full therapeutic replacement for intravenous anti-emetic drugs that would have otherwise been 
administered at the time of cancer chemotherapy. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. Although the requested ondansetron is an oral anti-emetic drug, the ondansetron is not 
being used as a full therapeutic replacement for intravenous (IV) anti-emetic drugs that would have otherwise 
been administered at the time of cancer chemotherapy treatment. Therefore, the requested use of ondansetron is 
not covered by Medicare Part B benefits. Therefore, we decided that the Plan does not have to pre-approve 
ondansetron tablets.  
 
Benefits for ondansetron 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 copayments for the inner ear surgeries provided from 
March 7, 2022, to April 13, 2022. 
 
You asked the Plan to waive the copayments for the outpatient hospital services. You say that you never went 
to the outpatient hospital. 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 $295 
copayment for outpatient hospital services.  
 
You have been asked to pay a $885 copayment for outpatient hospital services ($295 copay x 3 visits = $885). 
The outpatient hospital services fall 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 copayments for the inner ear surgeries provided from March 7, 2022, to April 13, 
2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for outpatient observation on July 20, 2021. 
 
You asked the Plan to waive the copayment for outpatient observation. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says that the cost sharing you are being charged 
is correct. 
 
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. Without the correct Evidence of Coverage (EOC), there is no way of knowing 
whether the copayment being charged is correct.  Therefore, we decided that the Plan has to waive the 
copayment for outpatient observation on July 20, 2021.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
October 5, 2021. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you met your maximum 
out-of-pocket amount for the year before this date of 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 $250 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $250 copayment for the ambulance services. The ambulance services fall within 
the Ambulance 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 
ambulance services provided on October 5, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a duplex scan of extremity veins provided 
on October 6, 2021. 
 
You asked the Plan to waive the copayment for a duplex scan. You say that this test needed to be done because 
of a reaction caused from the Covid 19 vaccine. Therefore, you should not need to pay for this copayment. The 
Plan denied your request. The Plan says the copayment that was 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 $130 
copayment for radiological diagnostic service.  
 
You have been asked to pay a $130 copayment for a duplex scan. A duplex scan falls within the Other 
Outpatient Diagnostic Tests - Radiological Diagnostic Services, Not Including X-Rays 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 duplex scan of extremity veins provided on October 6, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on November 29, 2021. 
 
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 the cost sharing you are being 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 $25 
copayment for each specialists office visit. Covered services include but are not limited to radiologic 
examination and x-rays. 
 
You have been asked to pay a $25 copayment for office visit. Office visits fall within the Outpatient basic 
radiological 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 office visit on 
November 29, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency department visit provided 
on May 16, 2022. 
 
You asked the Plan to waive the copayment for the emergency department visit. You say that the provider 
didn't properly care for your wound. 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 $120 
copayment for each emergency room visit.  
 
You have been asked to pay a $120 copayment for the emergency department visit. The emergency department 
visit falls within the Emergency 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 emergency department visit provided on May 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost sharing for the continuous positive airway pressure 
(cpap) device and nasal interface provided from February 9, 2022, to June 20, 2022. 
 
You asked the Plan to reduce the cost sharing for the cpap device and nasal interface. You say that you are 
appealing this cost-sharing. 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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay a 20% coinsurance for the cpap device and nasal interface. The cpap device and 
nasal interface falls within the Durable Medical Equipment (DME) and Related Supplies benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the cost sharing for the continuous positive airway pressure (cpap) device and 
nasal interface provided from February 9, 2022, to June 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a hydration infusion provided on April 13, 
2022. 
 
You asked the Plan to waive the copayment for a hydration infusion. You say that you are going through 
cancer treatments and feel this should be a covered service. The Plan denied your request. The Plan says the 
copayment that was 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 $230 
copayment for outpatient infusion therapy.  
 
You have been asked to pay the allowed amount of $199.80, which is less than the $230 copayment for a 
hydration infusion. A hydration infusion 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 a hydration infusion provided on April 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the catheters provided from January 1, 
2022, to May 6, 2022. 
 
You asked the Plan to waive the deductible for the catheters. You say that you cannot afford this, and you did 
not know the provider is out-of-network. 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. Your 
contract with the Plan says that there is a $1500 deductible which applies to Durable Medical Equipment 
(DME) and Related Supplies. At the time these claims were processed, $0 of the $1500 deductible had been 
met. The allowed amount of these claims is $266.40 per claim, resulting in a deductible amount of $1332. 
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Durable 
Medical Equipment (DME) and Related Supplies. The Plan has followed Medicare rules by clearly disclosing 
in the contract that there is a $1500 deductible which applies to Durable Medical Equipment (DME) and 
Related Supplies. This cost sharing is a contractual obligation that had not been met at the time the catheters 
was received on January 1, 2022, to May 6, 2022. Therefore, we decided that the Plan does not have to waive 
the deductible for the catheters provided from January 1, 2022, to May 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a Computed Tomography (CT) Scan 
provided on April 14, 2022. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you did not have a copayment like this 
the last time you had a CT scan done, so why do you have one now? The facility usually refunds them. The 
Plan denied your request. The Plan says the plan states that the copayment 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 must pay a $225 
copayment for diagnostic radiology.  
 
You have been asked to pay a $225 copayment for a CT scan. A CT scan 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 Computed Tomography (CT) Scan provided on April 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 4, 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 May 4, 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 October 28, 
2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that you are appealing this cost-
sharing. 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 $15 
copayment for a primary care physician's office visit.  
 
You have been asked to pay a $15 copayment for the office visit. The 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 copayment for the office visit provided on October 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cataract surgery provided on January 5, 
2022. 
 
You asked the Plan to waive the copayment for cataract surgery. You say that you had no idea that you would 
have such a large copayment for this procedure. The Plan denied your request. The Plan says the copayment 
that was 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 $195 
copayment for all other Ambulatory Surgical Center (ASC) services.  
 
You have been asked to pay a $195 copayment for cataract surgery. 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.  Therefore, we decided that the Plan does not have to waive the copayment for cataract surgery provided on 
January 5, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency department services 
provided on March 11, 2022. 
 
You asked the Plan to waive the copayment for the emergency department services. You say that the provider 
told you they would cover all your charges in regard to the slip and fall at their facility. 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 $90 
copayment for an emergency room visit.  
 
You have been asked to pay a $90 copayment for an emergency room visit. The emergency department 
services fall within the Emergency 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 emergency department services provided on March 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services on March 04, 2022. 
 
You asked the Plan to waive the copayment for lab services. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being 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 $10 
copayment per day for other Medicare-covered laboratory tests that are not FIT tests. Covered services include 
but are not limited to laboratory tests. 
 
You have been asked to pay a $10 copayment for lab services. Lab services 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 lab services on March 04, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for electrocardiogram (EKG) on May 02, 
2022. 
 
You asked the Plan to waive the copayment for EKG. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being 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 $65 
copayment for each covered diagnostic procedure or test at a network doctor's office. Covered services include 
but are not limited to other outpatient diagnostic tests. The provider billed in the amount of $35 and allowed 
amount is $13.91. This is less than the copayment amount. Therefore, results in the total cost sharing amount of 
$13.91. 
 
 
 
 You have been asked to pay a $13.91 copayment, which is less than the copayment for EKG. EKG 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 electrocardiogram (EKG) on May 02, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve rituximab agent (Ruxience). 
 
You asked the Plan to pre-approve Ruxience. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Ruxience. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of Extranodal marginal zone B-cell lymphoma of mucosa-associated 
lymphoid tissue [MALT-lymphoma]. The documentation does not support that the enrollee has tried and failed 
Rituxan or Riabni. The documentation does not support that Rituxan or Riabni would likely be less effective 
and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not criteria for the requested 
drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ruxience have not been met. Therefore, we decided that the Plan does not have 
to pre-approve rituximab agent (Ruxience).