Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the interrogation device evaluation services 
(G2066) provided on July 6, 2021 to November 9, 2021 
 
You asked the Plan to waive the copayment for the interrogation device evaluation services. You say that the 
services should be covered in full. The Plan denied your request. The Plan says the cost-sharing 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $95 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 You have been asked to pay a $229.7 copayment for 5 interrogation device evaluation services ($45.94 x 5 = 
$229.7), which is less than the standard $95 copayment per visit. Interrogation device evaluation services fall 
within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the interrogation device evaluation services (G2066) provided on 
July 6, 2021 to November 9, 2021
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services provided 
on August 8, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you were informed 
that the provider was out of network and you should not be responsible for the 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 $320 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $320 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 August 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an angioplasty (36902, 36908) provided on November 11, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an angioplasty. You say that the provider was unable to obtain an authorization 
for these services. You also say that the surgeon provided medical service, which would be more appropriate 
based on the patient's medical necessity. The Plan denied your request. The Plan says this provider is not a 
network provider with the Plan and the services were not referred by a network provider or rendered in an in-
network facility. The Plan also says that they have also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 angioplasty (36902, 36908) provided on 
November 11, 2021, 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 an abatacept 10mg injection (J0129) and 
chemotherapy services (96413) provided on March 15, 2021. 
 
You asked the Plan to waive the coinsurance for the abatacept 10mg injection and chemotherapy services. You 
say that the coinsurance should be covered in full as they would have never received the services if they knew 
the cost beforehand. The Plan denied your request. The Plan says the coinsurance 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 (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a 20% coinsurance for Medicare Part B prescription drugs.  
 
 The enrollee has been asked to pay a 20% coinsurance for an abatacept injection and chemotherapy services 
(total allowed is $4,405.93 x 20% = $881.19). Abatacept injections and chemotherapy services fall within the 
Medicare Part B prescription drugs 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 
coinsurance for an abatacept 10mg injection (J0129) and chemotherapy services (96413) provided on March 
15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for breast prosthesis items provided on 
October 23, 2021. 
 
You asked the Plan to waive the coinsurance for the breast prosthesis items. You say that the items were fully 
covered previously. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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 prosthetic devices, supplies related to prosthetic devices, and orthotics. 
 
 
 Item Allowed Amount 20% Coinsurance 
Breast Prosthesis, Silicone $273.55 $54.71 
Mastectomy Form $163.37 $32.67 
Mastectomy Bra $173.40 $34.68 
Total:  $122.06 
 
You have been asked to pay $122.06, which is 20% of the allowed amount for the breast prosthesis items. The 
breast prosthesis items fall within the Prosthetic Devices 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 breast prosthesis items provided on October 23, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. 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. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 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 home health services. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the records do not show that 
skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve 
the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level 
of function and/or prevent deterioration. There was no provided home evaluation showing deficits and lack of 
ability of her with her husband's help to perform regular exercises to justify home health physical therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 home health physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 10 home health PT visits. 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. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 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 10 home health PT visits. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found you do not have documented, 
ongoing, skilled PT needs. You are functioning at a level commiserate with a lower level of care. As such, the 
requested, ongoing, home health PT services are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 home health PT visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 10 home health physical therapy (PT) visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a mammography (76641) provided on 
October 25, 2021. 
 
You asked the Plan to waive the copayment for the mammography. You say that the services should be covered 
in full as it was a preventative service. The Plan denied your request. The Plan says the services are not 
considered a preventative service and falls under diagnostic services, therefore, the copayment has applied 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $125 copayment for a mammography. Mammographys fall within the 
Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a mammography (76641) provided on October 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits to be rendered by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render 
the requested services. 
 
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. 
 
You are not a network provider with the Plan. The Plan has network providers available who can provide the 
services at issue in this appeal. We found no exception that would require the Plan to pre-approve these 
services. Therefore, we decided that the Plan does not have to pre-approve office visits to be rendered by an 
out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Restasis 0.05% eye emulsion. 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary for dry 
eye syndrome of bilateral lacrimal glands. The Plan denied your request. The Plan says the requested drug is 
intended for patient self-administration. 
 
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 Restasis 0.05% eye 
emulsion.  
 
Benefits for the medication 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 an urgent care visit provided on November 
17, 2021. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that the services should be 
covered in full. The Plan denied your request. The Plan says the cost-sharing 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for Urgently needed services.  
 
 
  You have been asked to pay a $50 copayment for an urgent care visit. 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 urgent care visit provided on November 17, 2021.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance transportation (A0427, A0425) provided June 2, 2021. 
 
You asked the Plan to pay for the ambulance transportation. You say that the ambulance services were 
medically necessary. The Plan denied your request. The Plan says that the enrollee was an inpatient at the time 
services were provided and the ambulance transport is not eligible for separate payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
We find that CPT codes A0427 & A0425 are supported in the medical record. Specifically, the plan has 
provided no documentation to show that the enrollee was an inpatient. The ambulance run sheet shows that the 
enrollee was transported from home. Based on this information, we decided that Medicare rules for coverage of 
the ambulance transportation have been met. Therefore, we decided that the Plan has to pay for ambulance 
transportation (A0427, A0425) provided June 2, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dexlansoprazole. 
 
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 self-administered drugs are not covered. 
 
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 dexlansoprazole.  
 
Benefits for these services 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 an office visit provided on August 26, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you were not aware the provider was an out-of-
network provider. The Plan denied your request. The Plan says the rendering provider is an out-of-network 
provider, and the services was not referred 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 an office visit provided on August 26, 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 copayments for radiation therapy treatments provided 
from July 19, 2021, to September 17, 2021. 
 
You asked the Plan to waive the copayments for the radiation therapy. You say that you do not know why you 
received this 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 $60 
copayment for each therapeutic radiological service.  
 
You have been asked to pay a $60 copayment for each radiation therapy visit. The file shows a total of 32 visits 
between July 19, 2021, and September 17, 2021. The total amount for all visits is $1,920 ($60 copayment x 32 visits = $1,920). The radiation therapy 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 copayments for radiation therapy 
treatments provided from July 19, 2021, to September 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on September 9, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the service provided is a covered service 
and the claim should be paid. The Plan denied your request. The Plan says the rendering provider is an out-of-
network provider and there was no referral from an in-network provider or an approved authorization. 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 laboratory services provided on September 9, 
2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rhopressa. 
 
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 self-administered drugs are not covered. 
 
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 Rhopressa.  
 
Benefits for these services 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Ipratropium 0.03% spray. 
 
You asked the Plan to pre-approve the Ipratropium 0.03% spray. You say that the item is medically necessary. 
The Plan denied your request. The Plan says this is a self-administered drug. 
 
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 the Ipratropium 0.03% 
spray.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an abatacept 10mg injection (J0129) 
provided on February 10, 2021. 
 
You asked the Plan to waive the coinsurance for the abatacept 10mg injection. You say that the coinsurance 
should be covered in full as they would have never received the services if they knew the cost beforehand. The 
Plan denied your request. The Plan says the coinsurance 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 (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a 20% coinsurance for Medicare Part B prescription drugs.  
 
 
  The enrollee has been asked to pay a 20% coinsurance for an abatacept injection (allowed is $4,265.03 x 20% = 
$853.01). Abatacept injections fall within the Medicare Part B prescription drugs 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 coinsurance for an abatacept 10mg injection (J0129) provided on February 10, 
2021.