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

 
We decided that the Plan does not have to pay for self-administered drugs provided from December 5, 2022, to 
December 6, 2022. 
 
You asked the Plan to pay for self-administered drugs. You say that this should be covered. The Plan denied 
your request. The Plan says self-administered drugs are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
from December 5, 2022, to December 6, 2022.  
 Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the infusion therapy services provided from 
September 3, 2022, to September 22, 2022. 
 
You asked the Plan to waive the copayment for the infusion therapy services. You say that you already met 
your out-of-pocket maximum. 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 $425 
copayment for Medicare-covered surgery or other services provided at an outpatient hospital, including but not 
limited to hospital or other facility charges and physician or surgical charges. 
 
 
 
 You have been asked to pay a $4090.46 copayment for the infusion therapy services ($225.21 allowed amount 
x 18 services = $4053.78). The Plan is only holding you responsible for a $36.68 copayment for the last service 
because your out-of-pocket maximum was met partway through the processing of the claim. This makes the 
total copayment you are being asked to pay for the infusion therapy services $4090.46 ($4053.78 + $36.68 = 
$4090.46). These items/services fall 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 infusion therapy services provided from September 3, 2022, to September 22, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre. 
 
You asked the Plan to pre-approve a FreeStyle Libre. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has 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 indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a FreeStyle 
Libre have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial nursing facility care provided on September 6, 2022. 
 
You asked the Plan to pay for initial nursing facility care. 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 initial nursing facility care provided on September 6, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on December 7, 2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that there are no network providers 
available to provide your specific care. The Plan denied your request. The Plan says this provider is not eligible 
to participate in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on 
December 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each home ventilator rental provided on 
October 15, 2022, to November 15, 2022. 
 
You asked the Plan to waive the coinsurance for each home ventilator rental. You say that you were not told 
about the monthly cost of this equipment. 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 durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for each home ventilator rental. This item/service falls within the 
durable medical equipment 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. The total amount you owe for each ventilator rental is $160.31 
($801.57 allowed amount x 20% coinsurance = $160.31). Therefore, we decided that the Plan does not have to 
waive the coinsurance for each home ventilator rental provided on October 15, 2022, to November 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the myocardial perfusion imaging 
performed on November 8, 2022. 
 
You asked the Plan to waive the cost sharing for the imaging. You say that you do not agree with the cost 
sharing applied to this service. 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 covered diagnostic radiology services in the outpatient department of a network hospital or 
facility. 
 
 
 
 
 You have been asked to pay a $16.51 coinsurance for the imaging ($82.57 allowed amount x .20 = $16.51). 
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 cost sharing for the myocardial perfusion imaging performed 
on November 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment (DME) 
provided on October 28, 2021, to September 28, 2022. 
 
You asked the Plan to waive the coinsurance for DME. You say that you disagree with the coinsurance. 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 durable medical equipment (DME).  
 
You have been asked to pay a 20% coinsurance for DME. The total allowed amount for the DME is $1,626.11. 
You are being asked to pay $325.22 ($1,626.11 x 20% = $325.22). This item/service falls within the durable 
medical equipment (DME) 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 durable 
medical equipment (DME) provided on October 28, 2021, to September 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an out-of-network office visit provided on 
October 11, 2022. 
 
You asked the Plan to waive the cost share for an out-of-network office visit. 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. Your 
contract with the Plan says that there is a $500 deductible which applies to out-of-network 
physician/practitioner services/primary care provider.  
 
The item or service you asked the Plan to waive the cost share for falls within the out-of-network 
physician/practitioner services/primary care provider benefit category. The Plan has followed Medicare rules 
by clearly disclosing in the contract that there is a $500 deductible which applies to out-of-network 
physician/practitioner services/primary care provider. The total amount you are being asked to pay is $125.70 
towards your deductible. This cost sharing is a contractual obligation that had not been met at the time an out-
of-network office visit was received on October 11, 2022. Therefore, we decided that the Plan does not have to 
waive the cost share for an out-of-network office visit provided on October 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Illumya. 
 
You asked the Plan to pre-approve Illumya. You say that the requested Illumya is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail three preferred biologic disease-
modifying medications. 
 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 Illumya. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the record indicates that the 
enrollee has Psoriasis vulgaris. The requested medication is a new start. The provided records do not indicate 
that the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that 
the enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one 
alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Illumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Illumya.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 provided on March 21, 2022. 
 
You asked the Plan to pay for procedure code 99223. You say that the medical records support the billing of 
code 99223 provided on March 21, 2022. The Plan denied your request. The Plan says the medical records do 
not support the billing of code 99223 provided on March 21, 2022. 
 
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, the CPT Code Manual definition of code 99223 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit.  
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 99223. Our reviewer says that the medical 
records do not support the billing of code 99223 provided on March 21, 2022. Our reviewer found the review 
indicates that the enrollee was evaluated on March 21, 2022. She had a urinary tract infection (UTI) with 
computed tomography (CT) evidence of right nephrolithiasis/pyelonephritis. She was treated with IV fluids/IV 
antibiotics. The reviewed documentation indicates that code 99223 was not supported in the medical records. 
Specifically, there was no documentation of a comprehensive history. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99223 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99223 provided on March 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the trigger point injection provided on 
October 17, 2022. 
 
You asked the Plan to waive the copayment for the trigger point injection. You say that you do not know why 
the Plan did not fully pay for this service. 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 $370 
copayment for in-network outpatient surgery at an outpatient hospital facility. 
 
You have been asked to pay a $370 copayment for the trigger point injection. This item/service falls within the 
in-network outpatient surgery at an outpatient hospital 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 trigger point injection provided on October 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for chiropractic services provided on October 
04, 2022. 
 
You asked the Plan to waive the copayment for chiropractic services. 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 $20 
copayment for chiropractic services. 
 
You have been asked to pay a $20 copayment for chiropractic services. This item/service falls within the 
chiropractic 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 chiropractic services 
provided on October 04, 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 
April 25, 2022, to April 28, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you want these services 
fully covered. 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 $250 
copayment per day for days 1-7 of each inpatient hospital stay.  
 
You have been asked to pay a $250 copayment per day for days 1-3 of the inpatient hospital stay. You have not 
been charged after day three or for your day of discharge. These items/services fall 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 from April 25, 2022, to April 28, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a take-home supply of methadone (code G2078) provided on  
December 12, 2022. 
 
You asked the Plan to pay for the take-home supply of methadone. The Plan denied your request. The Plan says 
that an individual provider cannot bill for OTP services. 
 
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 OTP is the billing provider and is Substance Abuse and Mental 
Health Services Administration (SAMHSA) certified. The rules cited by the Plan do not provide a valid reason 
to deny this claim given that the OTP meets the Medicare coverage criteria. This provider continues to use the 
professional claim, which is allowed under Medicare rules. Therefore, we decided that the Plan has to pay for a 
take-home supply of methadone (code G2078) provided on December 12, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the inpatient hospital stay provided from 
June 12, 2022, to June 14, 2022 
 
You asked the Plan to waive the coinsurance for the inpatient hospital stay. You say that the care was 
unacceptable and do not want to pay the coinsurance. 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 10% 
coinsurance for each out-of-network Medicare-covered hospital stay each time you are admitted.  
 
You have been asked to pay up to 10% coinsurance for the inpatient hospital stay. You have been asked to pay 
a total of $661.75. 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 coinsurance for the inpatient hospital stay provided from June 12, 2022, to June 14, 
2022
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on October 
12, 2022. 
 
You asked the Plan to waive the copayment for laboratory services. 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 $45 
copayment for outpatient diagnostic tests/lab services/outpatient hospital. 
 
You have been asked to pay a $45 copayment for laboratory services. This item/service falls within the 
outpatient diagnostic tests/lab services/outpatient hospital 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 laboratory services provided on October 12, 2022.