Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on April 02, 2022, to 
April 29, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $200 copayment for medically necessary inpatient hospital care. Includes inpatient acute, inpatient 
rehabilitation, long-term care hospitals and other types of inpatient hospital services. Inpatient hospital care 
starts the day you are formally admitted to the hospital with a doctors order. The day before you are 
discharged is your last inpatient day. The provider billed in the amount of $26,924.32 and the allowed amount 
is $1,556. The Plan paid $1,461.11. $1,556 - $1,461.11 = $94.89. This is less than the copayment amount. 
Therefore, results in the total cost sharing amount of $94.89. 
 
 
 The enrollee has been asked to pay a $94.89 copayment, which is less than the copayment for inpatient hospital 
stay. This item/service falls within the Inpatient hospital 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 inpatient hospital stay on April 02, 2022, to April 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided on June 30, 2022. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you were following the orders of your 
primary care and feel you have lost money for no reason. You say that you did not need the x-ray and physical 
therapy suggested by provider. 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 x-rays taken in a physician's office and $130 copayment for x-rays taken at any other location.  
 
You have been asked to pay $73.97, which is less than the standard $130 copayment for an x-ray. 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 an x-ray provided on June 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic x-ray provided on July 21, 2022. 
 
You asked the Plan to waive the copayment for diagnostic x-ray. You say that you were not aware that of the 
cost-share applied to a mammogram if it turns from screening to diagnostic. You say that you believe all 
mammograms should no apply copayments. 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 $50 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $50 copayment for diagnostic x-ray. This item/service falls within the outpatient 
diagnostic test 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 diagnostic x-ray provided 
on July 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve the Prolia. You say that Prolia is medically necessary. The Plan denied your 
request. The Plan says a trial of zoledronic acid or pamidronate is required before alternatives can be 
considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Prolia. Our reviewer says that Prolia 
is not medically necessary. Our physician reviewer found the records show no trial of the plan preferred drugs, 
or any reason they would be unsafe or ineffective. 
 
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 Prolia have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Prolia (J0897).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on March 13, 
2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you are on a limited income 
and depend on social security and anything extra you will not be able to cover. 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 $125 
copayment for ambulance services. 
 
You have been asked to pay a $125 copayment for ambulance transport. This item/service 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 transport 
provided on March 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiological services (64493, 64495, 64494) provided on 
April 29, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the radiological services. You say that although the provider is out-of-network, 
the enrollee cannot choose the radiologist who reads their report. The Plan denied your request. The Plan says 
the services were not urgent or emergent and the services could have been rendered by a Plan 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 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 radiological services (64493, 64495, 64494) 
provided on April 29, 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 oxygen equipment on July 09, 2022, to 
August 08, 2022. 
 
You asked the Plan to waive the coinsurance for oxygen equipment. You say that you believe the DME should 
be 10% coinsurance, not 20% coinsurance. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment (DME) and related supplies. Covered items include, but are not 
limited to wheelchairs, crutches, powered mattress system, diabetic supplies, hospital beds ordered by a 
provider for use in the home, IV infusion pumps, speech-generating devices, oxygen equipment, nebulizers, 
and walkers. The provider billed in the amount of $220 and the allowed amount is $115.33. $115.33 x 20% = 
$23.07. Therefore, results in the total cost sharing amount of $23.07. 
 
 
 You have been asked to pay a 20% coinsurance for oxygen equipment. 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 oxygen equipment on July 09, 2022, to August 08, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy services provided from October 11, 
2021, to October 31, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for occupational therapy services. You say that you want the Plan to reconsider 
payment for the services. The Plan denied your request. The Plan says the services were not authorized, nor 
were they urgent or emergent. The services could have been provided in-network. 
 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 occupational therapy services provided from 
October 11, 2021, to October 31, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint (SIJ) injection. 
 
You asked the Plan to pre-approve an SIJ injection. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 an SIJ injection. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found in this case, there is no documentation 
on physical examination of three (3) or more positive tests results. The clinical value and effectiveness of an 
SIJ injection in the absence of tenderness and negative provocative testing results have not been demonstrated 
in the peer-reviewed literature. The review has determined that the service at issue is not medically reasonable 
or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an SIJ injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac joint (SIJ) injection.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on June 21, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you would 
like to appeal this service because you cannot pay the bill. The Plan denied your request. The Plan says this 
service is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 21, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on June 21, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on April 15, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you think 
you saved the insurance company thousands of dollars by declining transport to the hospital. You also say that 
calling 911 was necessary, and should be covered by your insurance. The Plan denied your request. The Plan 
says non-transports by an ambulance are not covered by Medicare or your plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 15, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on April 15, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Enhertu. 
 
You asked the Plan to pre-approve Enhertu. 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 Medicare may pay for unlabeled uses for FDA-
approved 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 Enhertu. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the requested use of drug is not FDA-
approved for the enrollees diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Enhertu have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Enhertu.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a certolizumab pegol injection (J0717) 
provided on June 10, 2022 to July 8, 2022. 
 
You asked the Plan to waive the coinsurance for the certolizumab pegol injection. You say that the services 
should be covered as you disagree with the denial. 
 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.  
 
 
  You have been asked to pay a 20% coinsurance for the certolizumab pegol injection. 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 a certolizumab pegol injection (J0717) provided on June 10, 2022 to July 8, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service July 19, 
2022. 
 You asked the Plan to pay for procedure code 76700. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for 
code 93976. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76700 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76700 billed for date of service July 19, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for colonoscopy provided on June 07, 2022. 
 
You asked the Plan to waive the copayment for colonoscopy. You say that you should not have to pay for the 
service. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for outpatient procedure benefits. 
 
You have been asked to pay a $250 copayment for colonoscopy. This item/service falls within the outpatient 
procedure benefits 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 colonoscopy 
provided on June 07, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic test provided on 
March 11, 2022. 
 
You asked the Plan to waive the copayment for outpatient diagnostic test. You say that you are requesting 
reconsideration stating you went in and was told you needed to go in for a second MRI so you would not be 
responsible for those charges. 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 $275 
copayment for outpatient hospital.  
 
You have been asked to pay $230.49, which is less than the $275 copayment for outpatient diagnostic test. This 
item/service falls within the outpatient hospital benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for outpatient diagnostic test provided on March 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided on July 20, 2022. 
 
You asked the Plan to waive the copayment for the x-ray. You say that you were advised by the Plan 
representative when you called there would be no 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 $50 
copayment per in-network provider, for each date of service.  
 
You have been asked to pay a total of $43.15, which is less than the standard copayment. The x-ray 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 an x-ray provided on July 20, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the private duty/independent nursing services (T1000) 
provided from January 4, 2021, to June 7, 2021. 
 
You asked the Plan to pay for the private duty/independent nursing services. The Plan denied your request. The 
Plan says it was confirmed that the treating provider is not included in Medicares Supplier Directory as a 
certified provider and there were providers available for the enrollee to have received the services. 
 
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items 
or services, a provider or supplier must be enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the private duty/independent nursing services have not been met. This provider is not part of the 
Medicare program and is not payable. Therefore, we decided that the Plan does not have to pay for the private 
duty/independent nursing services (T1000) provided from January 4, 2021, to June 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and electrocardiogram (EKG) provided on 
September 29, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and EKG. You say that a referral was received for services. The 
Plan denied your request. The Plan says a referral was made, however there are network providers available to 
provide necessary care to the enrollee. Authorization for services 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 and electrocardiogram (EKG) 
provided on September 29, 2021, by an out-of-network (OON) provider.