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

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of lower 
extremities provided on July 28, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that the charges should have been 
included in your surgery bill. 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 $125 
copayment for radiological diagnostic services, such as CT scans.  
 
You have been asked to pay a $125 copayment for the CT scan. The 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 of lower extremities provided on July 28, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Truxima for the enrollee. 
 
You asked the Plan to pre-approve Truxima. You say that this is medically necessary. The Plan denied your 
request. The Plan says that that the accepted use of this drug for the enrollee's illness requires the enrollee is not 
using as maintenance therapy. 
 
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 Truxima. Our reviewer says that 
Truxima is medically reasonable and necessary. Truxima is not FDA-approved for the enrollees diagnosis. 
The use of Truxima is supported by one of the major drug compendia or by clinical research that appears in a 
CMS-approved medical journal. Truxima is safe and effective and otherwise reasonable and necessary for this 
enrollee. Our physician reviewer found that the enrollee's condition meets criteria for coverage of Truxima. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Truxima have not been met. Therefore, we decided that the Plan has to pre-
approve Truxima for the enrollee.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental items. You say that your dentures do not fit properly. The Plan 
denied your request. The Plan says the frequency limit has been reached. 
 
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 and dentures are listed as covered, the 
frequency limit has been exceeded. The record shows that you previously received dentures on January 28, 
2020. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and 
a complete lower denture (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nasal interface (A7034), pillow (A7033), nasal pillow 
(A7029), and foam diffusers (E1399), provided on October 13, 2021. 
 
You asked the Plan to pay for the continuous positive airway pressure (CPAP) supplies. You say that the items 
should be covered. The Plan denied your request. The Plan says the items were obtained through a provider 
that is not enrolled 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 the nasal interface (A7034), pillow 
(A7033), nasal pillow (A7029), and foam diffusers (E1399), provided on October 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power mobility device (K0003). 
 
You asked the Plan to pre-approve a power mobility device. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that 
Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power mobility device (K0003).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cystoscopy performed on October 18, 
2021. 
 
You asked the Plan to waive the copayment for the cystoscopy. You say that you feel this is a diagnostic test 
and not a surgical procedure. 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 surgery or other services performed at an outpatient hospital or ambulatory surgical center.  
 
 Please note that under the National Correct Coding Initiative (NCCI) Manual, cystoscopy procedures are listed 
as surgical in nature. Therefore, you have been asked to pay a $250 copayment for the cystoscopy. The 
cystoscopy 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 a 
cystoscopy performed on October 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient mental health services provided 
from July 25, 2021, to July 28, 2021. 
 
You asked the Plan to waive the copayment for the inpatient mental health services. You say that you would 
like financial assistance with the bills. 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 $250 per 
day for days 1-7 and $0 per day after day 7 for each inpatient mental health admission.  
 The file shows that you were in the hospital from July 25, 2021, to July 28, 2021, but there is no copayment for 
the discharge date. Therefore, you have been asked to pay $250 per day for the first 3 days of inpatient mental 
health services. The total for your stay is $750 ($250 copayment x 3 days = $750). The inpatient mental health 
services fall within the Inpatient Mental Health 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 inpatient mental health services provided from July 25, 2021, to July 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a joint injection provided on December 13, 
2021. 
 
You asked the Plan to waive the copayment for the injection. You say that you feel like these are padded 
charges from the provider. 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 $150 
copayment for surgery or other services provided to you at an outpatient hospital.  
 
You have been asked to pay a $150 copayment for the injection. The injection 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 a joint injection provided on December 13, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physician visit provided on September 29, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for a physician visit. You say that the facility failed to get proper authorization and 
the service provided was medically necessary. The Plan denied your request. The Plan says the rendering 
provider is an out-of-network provider and there was no referral that was authorized. 
  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 a physician visit provided on September 29, 2021, 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the vasectomy (55250). 
 
You asked the Plan to pre-approve the vasectomy (55250). You say that the members partner has had several 
ectopic pregnancies, is allergic to latex used in contraceptives and is being treated for health conditions. You 
say that the partner has done everything possible to take care of herself with contraceptives and they have not 
been effective. The Plan denied your request. The Plan says a vasectomy is not covered if the primary 
indication is sterilization. 
 
The Plan must follow Medicare rules. Medicare rules say that an elective hysterectomy, tubal ligation, and 
vasectomy are not covered if the primary indication for these procedures is sterilization. A sterilization that is 
performed because a physician believes another pregnancy would endanger the overall general health of the 
woman is not considered to be reasonable and necessary. 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the vasectomy (55250) have not been met. Specifically, a vasectomy is not covered when the 
primary indication is sterilization. Therefore, we decided that the Plan does not have to pre-approve the 
vasectomy (55250).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiologic examination of the hip (73502) provided on 
October 7, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a radiologic examination of the hip. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says this provider is out-of-network with the Plan, 
and authorization was not obtained prior to the services being rendered. 
 
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 a radiologic 
examination of the hip (73502) provided on October 7, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deducible for physical therapy services provided from 
October 25, 2021, to October 28, 2021. 
 
You asked the Plan to waive the deducible for the physical therapy services. You say that the services should 
be covered. The Plan denied your request. The Plan says the deductible applied correctly based on the services 
provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible which applies to Outpatient rehabilitation services.  
 
 
  The item or service you asked the Plan to waive the deducible for falls within the benefit category Outpatient 
rehabilitation services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$750 deductible which applies to Outpatient rehabilitation services. This cost sharing is a contractual obligation 
that had not been met at the time the physical therapy services was received on October 25, 2021, to October 
28, 2021. Therefore, we decided that the Plan does not have to waive the deducible for physical therapy 
services provided from October 25, 2021, to October 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Onetouch Verio flex meter (E0607). 
 
You asked the Plan to pre-approve the Onetouch Verio flex meter. You say that the item is medically 
necessary. The Plan denied your request. The Plan says preferred brands must be used. 
 The Plan follows Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the Durable Medical Equipment 
(DME) to only those preferred brands and manufacturers. 
 
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 Onetouch Verio flex meter. Our 
reviewer says that this item is not medically necessary. Our physician reviewer found there is no indication of 
the requested item being medically necessary over the Plan's preferred brands. 
 
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 Onetouch Verio flex meter have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the Onetouch Verio flex meter (E0607).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical dressings provided on September 24, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the surgical dressings. You say that the physician ordered the supplied and the 
supplies should be covered because they were medically necessary. The Plan denied your request. The Plan 
says the rendering provider is an out-of-network provider and there was no referral by an in-network provider. 
Also, the service rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the surgical dressings provided on September 24, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
November 19, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that this was a pre-op 
appointment and there should not be a copayment. 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 $45 
copayment for each specialist visit.  
 
The file shows that pre-op copayments are only waived when they are done the day before your procedure. 
Therefore, you have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit 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 a specialist office visit provided on November 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of luspatercept. 
 
You asked the Plan to pre-approve luspatercept. You say that a trial of luspatercept is planned for the enrollee's 
worsening clinical picture. The Plan denied your request. The Plan says the denial of authorization for this drug 
is correct, because there is not enough evidence that luspatercept is safe or helpful for the enrollee's condition. 
 
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 luspatercept. Our reviewer says that the 
enrollee does not meet the Medicare criteria for luspatercept. Our physician reviewer found the requested use 
of luspatercept is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. It 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 luspatercept have not been met. Therefore, we decided that the Plan does not 
have to pre-approve use of luspatercept.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services provided 
on July 25, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you would like 
financial assistance with the bills. 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 $220 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $220 copayment for the ambulance transportation. The ambulance transportation 
falls 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 ambulance transportation services provided on July 25, 
2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
October 21, 2021. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you cannot afford 
this copay. The Plan denied your request. The Plan says the copayment applied 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 $90 
copay for Medicare-covered emergency room visits.  
 
 
 
 You have been asked to pay a $90 copay for the emergency room services. The emergency room 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 room services provided on October 21, 2021.