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

 
We decided that the Plan does not have to waive the coinsurance for Part B drugs on January 05, 2022. 
 
You asked the Plan to waive the coinsurance for Part B drugs. 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 20% 
coinsurance for Medicare-covered Part B medications, including, but not limited to, chemotherapy and drugs 
used during outpatient diagnostic procedures. These drugs are covered under Part B of Original Medicare. 
Members of our plan receive coverage for these drugs through our plan. Covered drugs include drugs that 
usually arent self-administered by the patient and are injected or infused while you are getting physician, 
hospital outpatient, or ambulatory surgical center services. The provider billed in the amount of $283 and the 
allowed amount is $133.74. $133.74 x 20% = $26.75. The provider also billed in the amount of $7,826 and the 
allowed amount is $2,038.59. $2,038.59 x 20% = $407.72. $26.75 + $407.72 = $434.47. Therefore, results in 
the total cost sharing amount of $434.47. 
 You have been asked to pay a 20% coinsurance for Part B drugs. 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 Part B 
drugs on January 05, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for telehealth visit on June 09, 2022. 
 
You asked the Plan to waive the copayment for telehealth visit. 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 $45 
copayment for each covered visit or consultation in an outpatient location with a specialist. Covered services 
include telehealth services to diagnose, evaluate, or treat symptoms of a stroke, regardless of your location. 
 
You have been asked to pay a $45 copayment for telehealth visit. This item/service 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 telehealth visit on June 09, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for biofeedback treatments provided on March 
30, 2022, to April 27, 2022. 
 
You asked the Plan to waive the copayment for biofeedback treatments. You say that you were not notified that 
this would be coded as a procedure.It should not be. 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 $100 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $100 copayment for biofeedback treatments. This item/service 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. You had 4 visits, x $100 copayment each = $400. Therefore, we decided that the Plan does not have to waive the 
copayment for biofeedback treatments provided on March 30, 2022, to April 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic sonogram provided on April 
23, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic sonogram. You say that ths should be part of your 
mammogram screening and you should not have a 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 $75 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $75 copayment for a diagnostic sonogram. 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 diagnostic sonogram provided on April 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 22, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary. The Plan denied your 
request. The Plan says there wasn't an authorization for this visit, and it was not an emergency. 
 
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 March 22, 2022, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided from April 7, 
2022, to April 14, 2022. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that this copayment is too large to 
pay on a restricted income, and it would cause a financial hardship. 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 $295 
copayment each day for days 1 to 7 for inpatient hospital care ($285 x 7 days = $2065).  
 
You have been asked to pay a $2065 total copayment for an inpatient stay. 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 copayment for an inpatient 
stay provided from April 7, 2022, to April 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that orthotics will provide support to stabilize ankle 
motion. You need the insoles to be custom to prevent tissue damage which you are at risk due to severe 
deformity. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor and a segmental pneumatic 
appliance to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compressor and a segmental pneumatic appliance. You say that 
you are the only supplier in the enrollee's geographical area that can supply the prescribed equipment. The Plan 
denied your request. The Plan says you must receive your care from a network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compressor and a segmental pneumatic appliance to be provided by an out-of-network (OON) 
provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Androgel Gel. 
 
You asked the Plan to pre-approve Androgel Gel. The Plan denied your request. The Plan says this is not 
covered under the enrollee's Part B plan. 
 
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 pre-approve Androgel Gel.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa. 
 
You asked the Plan to pre-approve Gemtesa. You say that this is medically necessary. The Plan denied your 
request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan. 
 
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 pre-approve Gemtesa.  
 
Benefits for Gemtesa 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 pay for a home visit and urinalyses provided on March 21, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for a home visit and urinalyses. The Plan denied your request. The Plan says 
authorization was denied for this service. 
 
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 home visit and 
urinalyses provided on March 21, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the cost-share for an outpatient hospital observation stay provided on 
May 11, 2022. 
 
You asked the Plan to waive the cost-share for an outpatient hospital observation stay. You say that you were 
out of state when you experience a sudden and severe transient ischemic attack (TIA). You say that you were 
directed by your provider to go to the nearest emergency room. The Plan denied your request. The Plan says 
that the cost-share applied 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. The Plan did not provide evidence or claim information to show this claim can 
be applied to the deductible. This means that we cannot determine the cost you are being asked to pay is 
correct. Therefore, we decided that the Plan has to waive the cost-share for an outpatient hospital observation 
stay provided on May 11, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab tests on June 18, 2022. 
 
You asked the Plan to waive the copayment for lab tests. 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 $10 
copayment for 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 tests. 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 lab tests on June 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for magnetic resonance imaging (MRI) provided on April 26, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for MRI. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says the network primary care physician (PCP) or plan must give the enrollee approval in 
advance before the enrollee can use providers not in the plan's network. This is called a "referral." 
 
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 magnetic resonance imaging (MRI) provided on 
April 26, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Bio Compression Systems pneumatic compression 
pump. 
 
You asked the Plan to pre-approve the device. You say that the plan vendor confirmed they do not carry this 
device. The Plan denied your request. The Plan says medically necessary care is available in-network. 
 
The Plan must follow Medicare rules. Medicare rules say that contract suppliers are not required to furnish a 
specific brand name item or mode of delivery to a beneficiary unless prescribed by a physician or treating 
practitioner to avoid an adverse medical outcome.   
 
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 device. Our reviewer says that the 
requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found 
based on the medical records provided there is no documentation that the Bio Compression brand pneumatic 
compression device from an out-of-network vendor at issue in this case meets all Medicare criteria for being 
medically reasonable and necessary for the patient. The records do not document the features that the requested 
product has versus other brand name products and an explanation of how these features are necessary to avoid 
an adverse medical outcome as required by Medicare rules. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Bio Compression Systems pneumatic compression pump.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab work provided on March 24, 2022. 
 
You asked the Plan to waive the copayment for lab work. You say that you feel you are being charged unfairly. 
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 $15 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $15 copayment for lab work. 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 lab work provided on March 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that this provider performed your previous 
procedure. The Plan denied your request. The Plan says you must receive your care from a network provider 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Part B drugs on March 09, 2022. 
 
You asked the Plan to waive the coinsurance for Part B drugs. 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 20% 
coinsurance for Medicare-covered Part B medications, including, but not limited to, chemotherapy and drugs 
used during outpatient diagnostic procedures. These drugs are covered under Part B of Original Medicare. 
Members of our plan receive coverage for these drugs through our plan. Covered drugs include drugs that 
usually arent self-administered by the patient and are injected or infused while you are getting physician, 
hospital outpatient, or ambulatory surgical center services. The provider billed in the amount of $268 and the 
allowed amount is $133.74. $133.74 x 20% = $26.75. The provider also billed in the amount of $7,826 and the 
allowed amount is $2,038.63. $2,038.63 x 20% = $407.73. $26.75 + $407.73 = $434.48. Therefore, results in 
the total cost sharing amount of $434.48. 
 You have been asked to pay a 20% coinsurance for Part B drugs. 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 Part B 
drugs on March 09, 2022.