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

 
We decided that the Plan does not have to waive the copayment for outpatient surgery on April 11, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, 
including but not limited to hospital or other facility charges and physician or surgical charges. The provider 
billed in the amount of $425 and the allowed amount is $196.10. This is less than the copayment amount. 
Therefore, results in the total cost sharing amount of $196.10. 
 
 
 
 You have been asked to pay a $196.10 copayment, which is less than the copayment for outpatient surgery. 
Outpatient surgery falls within the Outpatient surgery and other medical services provided at hospital 
outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for outpatient surgery on April 11, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93380 billed for date of service February 18, 
2022. 
 
You asked the Plan to pay for procedure code 93380. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 93380 is bundled into payment for code 76536. 
 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 93380 
is a column II code to column I code 76536. 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 93380 billed for date of service February 18, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
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 step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has age-related 
osteoporosis without osteoporotic fracture. She has not tried and failed the Plan's rqeuired drugs, an oral 
bisphosphonate and zoledronic acid. The records do not show that the required drugs would be contraindicated 
or less effective; therefore, Prolia is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy visits provided from 
March 31, 2022, to May 5, 2022. 
 
You asked the Plan to waive the copayments for physical therapy visits. You say that you were told these 
services would be covered. Therefore, you feel these copayments should be waived. The Plan denied your 
request. The Plan says the copayment applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for outpatient rehabilitation services ($40 x 5 visits = $200).  
 
You have been asked to pay a $200 copayment for physical therapy visits. Physical therapy visits fall within 
the Outpatient Rehabilitation Services In-Network Medicare-Covered Therapy 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 copayments for physical therapy visits provided from March 31, 2022, to 
May 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0117U) provided January 24, 2022.  
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that to report a pharmacogenomics testing service, 
providers must submit the following information: The appropriate procedure code, 1 unit of service, & the 
appropriate DEX Z-code. 
 
We looked at the file and Medicare rules. The claim did not include a valid DEX Z-code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (0117U) provided January 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 18, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 
 The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 15, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 
 The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the copayment for an out-of-network (OON) 
specialist office visit provided on April 7, 2022. 
 
You asked the Plan to waive or reduce the copayment for the OON specialist visit. You say that the visit should 
be considered in-network. 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 $65 
copayment for each PCP or specialist visit with an out-of-network provider.  
 
The file shows that the Plan verified the provider is not a network provider. Therefore, you have been asked to 
pay a $65 copayment for the OON specialist visit. The OON specialist visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive or reduce the copayment for an out-of-network (OON) specialist office visit provided on April 7, 
2022.
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 6, 
2022, to April 10, 2022. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you were unaware of the 
copayment due for this service, therefore you feel you should not have to pay. The Plan denied your request. 
The Plan says the copayments applied were correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $403 
copayment per day, for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a $1,612 copayment for a 4-day inpatient stay ($403 x 4 days = $1,612). An 
inpatient stay 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 6, 2022, to April 10, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided 
from May 27, 2022, to May 28, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you were misinformed and 
misdiagnosed during the visit. 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 $90 
copayment for each emergency room visit.  
 
You have been asked to pay a $90 copayment for the ER visit. The ER visit 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 (ER) visit 
provided from May 27, 2022, to May 28, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
March 7, 2022. 
 
You asked the Plan to waive the copayment for the PT services. You say that you were not aware that you 
would owe $30 for each visit. 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 $30 
copayment for each physical therapy visit.  
 You have been asked to pay a $30 copayment for the PT services. The PT services fall within the Outpatient 
Rehabilitation 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 physical 
therapy (PT) services provided on March 7, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic ultrasound provided on March 
8, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic ultrasound. You say that you were unaware of this 
copayment at the time of your visit, and you cannot afford it. The Plan denied your request. The Plan says the 
copayment applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment for diagnostic procedures and tests.  
 
You have been asked to pay a $100 copayment for a diagnostic ultrasound. A diagnostic ultrasound falls within 
the Diagnostic Procedures and Tests 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 ultrasound provided on March 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for infusions provided from March 18, 2022, to 
March 24, 2022. 
 
You asked the Plan to waive the copayment for infusions. You say that you had no idea how much these 
infusions would cost. You would like a discount. The Plan denied your request. The Plan says the copayments 
applied were correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $335 
copayment for outpatient infusion therapy.  
 
You have been asked to pay the allowed amount of $187.58, which is less than the $335 for infusions. In total, 
you have been asked to pay $1313.06 ($187.58 x 7 days = $1313.06). Infusions falls within the Outpatient 
Infusion Therapy 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 infusions provided 
from March 18, 2022, to March 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Memantine tablet. 
 
You asked the Plan to pre-approve Memantine. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Memantine 
tablet.  
 Benefits for Memantine 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional reimbursement for an out-of-network (OON) seat 
lift mechanism provided on April 8, 2022. 
 
You asked the Plan to provide additional reimbursement for the OON seat lift. You say that you were under the 
impression that the provider was in-network. You say that you should be reimbursed more. The Plan denied 
your request. The Plan says you have been reimbursed the correct amount. 
 
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 $250 deductible which applies to certain items and services. 
 
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for durable medical 
equipment (DME), including seat lifts. 
 
The seat lift falls within the Durable Medical Equipment (DME) and Related Supplies benefit category. The 
Plan has followed Medicare rules by clearly disclosing in the contract that there is $250 deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not been met at the 
time the OON seat lift was provided on April 8, 2022.  
 
The file shows that the Plan has reimbursed their 80% responsibility for the seat lift, after the $250 deductible 
was met ($282.64 allowed amount - $250 deductible = $32.64. $32.64 x 80% Plan responsibility = $26.11). 
Please note that the Plan cannot reimburse costs in excess of the Medicare allowable amount. Therefore, we 
decided that the Plan does not have to provide additional reimbursement for an out-of-network (OON) seat lift 
mechanism provided on April 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
lumbar spine provided on April 26, 2022. 
 
You asked the Plan to waive the copayment for the CT scan. You say that the scan was necessary for your 
increasing back pain. 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 $225 
copayment for each CT scan.  
 
You have been asked to pay $107.09, which is less than the $225 copayment for the CT scan. The CT scan falls 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the lumbar spine provided on 
April 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for elbow nerve surgery performed on January 
18, 2022. 
 
You asked the Plan to waive the copayment for the elbow surgery. You say that the surgery was needed to 
correct the previous surgery. 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 $300 
copayment for surgery or services not provided at an ambulatory surgical center.  
 
You have been asked to pay a $300 copayment for the elbow surgery. The elbow surgery falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for elbow nerve surgery 
performed on January 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an intermittent urinary catheter provided 
on March 31, 2022. 
 
You asked the Plan to waive the coinsurance for the catheter. You say that you were not charged for the 
supplies 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 15% 
coinsurance for durable medical equipment (DME), including catheters.  
 
You have been asked to pay $35.50, which is 15% of the allowed amount for the catheter ($236.70 allowed 
amount x 15% coinsurance = $35.50). The catheter 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 intermittent 
urinary catheter provided on March 31, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the coinsurance for a vedolizumab injection 
provided on February 18, 2022. 
 
You asked the Plan to waive or reduce the coinsurance for the injection. You say that you were under the 
impression that this would be covered under Part D benefits. 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 Part B drugs.  
 
You have been asked to pay $934.04, which is 20% of the allowed amount for the injection ($4,670.19 allowed 
amount x 20% coinsurance = $934.04). The injection 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 or reduce the coinsurance for a vedolizumab 
injection provided on February 18, 2022.