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

 
We decided that the Plan does not have to waive the copayment for a CT scan provided on April 5, 2022. 
 
You asked the Plan to waive the copayment for a CT scan. You say that the first CT scan done was performed 
incorrectly causing the need for a second scan to be completed. 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 $150 
copayment per day, per provider for Medicare-covered diagnostic radiology services.  
 
You have been asked to pay a $150 copayment per day, per provider for a CT scan. This item/service falls 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a CT scan provided on April 5, 2022.  
 Your complaint about the first CT scan not being performed correctly causing the need for a second scan is not 
a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the 
Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services on August 12, 
2021. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for each emergency care visit. Emergency care refers to services that are: Furnished by a provider 
qualified to furnish emergency services, and Needed to evaluate or stabilize an emergency medical condition.  
 
You have been asked to pay a $90 copayment for emergency room services. This item/service 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 emergency room 
services on August 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a laryngoscopy provided on June 10, 2022. 
 
You asked the Plan to waive the copayment for a laryngoscopy. You say that you should not have to pay this 
copayment, as you were having this procedure due to covid. 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 hospital services. 
 
You have been asked to pay a $350 copayment for a laryngoscopy. This item/service falls 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 copayment for a laryngoscopy 
provided on June 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound on May 11, 2022. 
 
You asked the Plan to waive the copayment for ultrasound. You say that you think the copayment should be 
$40. 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 $165 
copayment for Outpatient diagnostic tests and therapeutic services and supplies. Medicare-covered radiological 
diagnostic services, not including X-rays, performed in a physicians office or at a free-standing facility (such 
as a radiology center or medical clinic). Covered services include but are not limited to other outpatient 
diagnostic tests - Radiological diagnostic services, not including x-rays. The provider billed in the amount of 
$285 and the allowed amount is $130.74. This is less than the copayment amount. Therefore, results in the total 
cost sharing amount of $130.74. 
 
 You have been asked to pay a $130.74 copayment, which is less than the copayment for ultrasound. This 
item/service falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for ultrasound on May 11, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
January 01, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you were triaged but 
never taken back and just went home as there was no where to wait. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for an emergency room visit. This item/service 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 an emergency room visit 
provided on January 01, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for orthopedic foot care and labs provided on 
January 7, 2022. 
 
You asked the Plan to waive the copayment for orthopedic foot care and labs. You say that no one told you 
how much this visit would be, and it would be a financial hardship on you. 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 $10 copayment on labs, and a $450 deductible which applies to 
outpatient diagnostic tests and therapeutic services and supplies ($450 + $10 = $460).  
 
The item or service you asked the Plan to waive the copayment for falls within the benefit category outpatient 
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $450 deductible and a $10 copayment which applies to outpatient 
diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not 
been met at the time orthopedic foot care and labs was received on January 7, 2022. Therefore, we decided that 
the Plan does not have to waive the copayment for orthopedic foot care and labs provided on January 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care on April 15, 2022. 
 
You asked the Plan to waive the copayment for urgent care. You say that you are requesting the reduction of a 
$50 copayment to a $10 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $50 copayment for each Medicare-covered urgent care facility visit. This copayment is not waived 
if you are admitted as an inpatient to the hospital within 24 hours for the same condition. Urgently needed 
services are provided to treat a non-emergency, unforeseen medical illness, injury, or condition that requires 
immediate medical care. Urgently needed services may be furnished by network providers or by out-of-
network providers when network providers are temporarily unavailable or inaccessible. 
 
 
 
 The enrollee has been asked to pay a $50 copayment for urgent care. This item/service falls within the Urgently 
needed services benefit category. This means that the enrollee has been asked to pay the correct amount based 
on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon 
enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for urgent care 
on April 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide. 
 
You asked the Plan to pre-approve a stair glide. You say that you are 85 years old and do not have a banister 
going from the first floor to the second. You have a knee injury that needs surgery because it is giving out. 
You've broken a rib and rotator cuff and you hit my head and injured my hands. The Plan denied your request. 
The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve phlebectomy. 
 You asked the Plan to pre-approve phlebectomy. 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 follows Medicare rules. Medicare rules say that invasive procedures for the treatment of varicose 
veins are considered medically reasonable and necessary when specific criteria are met. 
 
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 phlebectomy. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found no documentation of recent 
conservative treatment has been provided, nor specific documentation of ultrasound/doppler results which 
includes amount of reflux and venous measurements, despite multiple requests. The review has determined that 
the enrollee does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of phlebectomy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve phlebectomy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
sensor kit. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the criteria for coverage are not 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 the enrollee does not treat with 
insulin three or more times per day or use an insulin pump. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) sensor kit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paring or cutting of benign hyperkeratotic lesion provided on 
May 27, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for paring or cutting of benign hyperkeratotic lesion. You say that the member 
presented the incorrect insurance card at the time of service. Due to the patient misleading the office of 
incorrect insurance, the office was unable to obtain authorization. The Plan denied your request. The Plan says 
the provider is out-of-network and authorization is required prior to an out-of-network visit. 
 
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 paring or cutting of benign hyperkeratotic lesion 
provided on May 27, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an automatic external defibrillator 
provided on January 21, 2022. 
 
You asked the Plan to waive the coinsurance for an automatic external defibrillator. You say that you were 
never told at the time of receiving this item that there would be a cost associated with it. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment (DME) and related supplies. The allowed amount of this item is 
$2772.86 resulting in a $554.57 coinsurance ($2772.86 x 20% = $554.57). 
 
You have been asked to pay a $554.57 coinsurance for an automatic external defibrillator. This item/service 
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 waive the coinsurance for an automatic external defibrillator provided on 
January 21, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility stay provided from 
April 22, 2022, to June 10, 2022. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that many of these services are being 
billed as out-of-network, when they are not. 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 $178 copayment per day, for days 21 -100 for skilled nursing facility (SNF) care ($178 x 8 days = 
$1,424).  
 
The enrollee has been asked to pay a $1424 copayment for a SNF stay. This item/service falls within the skilled 
nursing facility (SNF) 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 a skilled nursing facility stay provided from 
April 22, 2022, to June 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy treatments provided on 
January 19, 2022. 
 
You asked the Plan to waive the coinsurance for chemotherapy treatments. You say that you already reached 
your Maximum Out Of Pocket (MOOP) cost and should not owe this. The Plan denied your request. The Plan 
says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs. The allowed amounts were $5,693.10 for the first 
injection, and $2,287.27 for the second injection ($5693.10 x 20% = $1138.62), ($2287.27 x 20% = $457.45), 
($1138.62 + $457.45 = $1596.07) 
 
You have been asked to pay a $1596.07 coinsurance for chemotherapy treatments. This item/service falls 
within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan.  This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the coinsurance for chemotherapy treatments provided on January 
19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 22, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on April 22, 2022 by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is weak and needs to regain their 
abilities. The enrollee has no one to care for them at home and the enrollee has trouble caring for their basic 
needs. The Plan denied your request. The Plan says criteria for admission to the IRF setting have not been met. 
The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollees medical problems are stable and there are no complex nursing or rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary 
care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (93005, 85027, 80048) provided on 
December 17, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 laboratory services (93005, 85027, 80048) 
provided on December 17, 2021 by an out-of-network (OON) provider.