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

 
We decided that the Plan does not have to waive the copayments for a pacemaker insertion procedure and an 
electrode repair procedure performed from April 12, 2022, to April 30, 2022. 
 
You asked the Plan to waive the copayments for the pacemaker insertion and electrode repair. You say that you 
were informed that you would not have to pay anything for the services. 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 $250 
copayment for surgery or services provided at an outpatient hospital.  
 
You have been asked to pay a $250 copayment each for the pacemaker insertion and electrode repair, for a total 
of $500. The pacemaker insertion and electrode repair fall 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 copayments for a pacemaker insertion procedure and an electrode repair 
procedure performed from April 12, 2022, to April 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 very heavy-duty power scooter (K0808). 
 
You asked the Plan to pre-approve a group 2 very heavy-duty power scooter (K0808). You say that you would 
like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested power 
scooter (K0808) is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The item at issue is a group 2 power scooter coded as K0808. This 
item is denied by Medicare for all indications. This means that Medicare rules for coverage of the power 
scooter coded as K0808 have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
group 2 very heavy-duty power scooter (K0808).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) provided on 
February 3, 2022. 
 
You asked the Plan to waive the copayment for the EKG. You say that you feel the EKG should be included 
with the office visit charge. 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 $20 
copayment for non-radiological diagnostic services, including EKG's.  
 
You have been asked to pay $15.14, which is less than the $20 copayment for the EKG. The EKG 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 electrocardiogram (EKG) provided on February 3, 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 23, 2021. 
 
You asked the Plan to waive the copayment for the PT services. You say that you were informed there would 
be no charge for the services. 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 $20 
copayment for physical therapy visits.  
 You have been asked to pay a $20 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 23, 2021.
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 18, 2021. 
 
You asked the Plan to waive the copayment for the PT services. You say that you were informed there would 
be no charge for the services. 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 $20 
copayment for physical therapy visits.  
 You have been asked to pay a $20 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 18, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy with biopsy performed on 
May 12, 2022. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that you cannot afford 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 $325 
copayment per visit for surgery or services provided at an outpatient hospital or ambulatory surgical center.  
 
The file shows that the billing code used was for a colonoscopy with a biopsy or polyp removal. This makes the 
procedure diagnostic instead of a screening. Therefore, you have been asked to pay a $325 copayment for the 
colonoscopy. The colonoscopy 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 a colonoscopy with biopsy performed on May 12, 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 15, 2021. 
 
You asked the Plan to waive the copayment for the PT services. You say that you were informed there would 
be no charge for the services. 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 $20 
copayment for physical therapy visits.  
 You have been asked to pay a $20 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 15, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility stay from January 
1, 2022, to January 22, 2022. 
 
You asked the Plan to waive the copayment for a skilled nursing facility stay. You say that you should not have 
to pay this copayment, it is too large. 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 $188 
copayment each day for days 21 to 44 for Skilled Nursing Facility (SNF) Care.  
 
You have been asked to pay a $1,504 copayment for an 8 day stay at a skilled nursing facility (8 days x $188 
per day = $1,504). A skilled nursing facility stay falls within the Skilled Nursing Facility (SNF) 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 a skilled nursing facility stay 
from January 1, 2022, to January 22, 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 25, 2021. 
 
You asked the Plan to waive the copayment for the PT services. You say that you were informed there would 
be no charge for the services. 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 $20 
copayment for physical therapy visits.  
 You have been asked to pay a $20 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 25, 2021.
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 
pelvis provided on February 24, 2022. 
 
You asked the Plan to waive the copayment for the CT scan. You say that the test was ordered by your doctor 
and should be covered. 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 $195 
copayment for diagnostic radiology services, including CT scans.  
 You have been asked to pay a $195 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 pelvis provided on February 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the copayment for a back injection performed on 
May 12, 2022. 
 
You asked the Plan to waive or reduce the copayment for the back injection. You say that you cannot afford 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 $390 
copayment per visit for surgery or services provided at an outpatient hospital or ambulatory surgical center.  
 
You have been asked to pay a $390 copayment for the back injection. The back injection 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 or reduce the copayment for a back injection 
performed on May 12, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy on February 21, 2022. 
 
You asked the Plan to waive the copayment for physical therapy. 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 $30 
copayment for each specialist visit for outpatient rehabilitation services. Covered services include physical 
therapy, occupational therapy, and speech language therapy. Outpatient rehabilitation services are provided in 
various outpatient settings, such as hospital outpatient departments, independent therapist offices, and 
Comprehensive Outpatient Rehabilitation Facilities (CORFs). 
 
 
 
 
 You have been asked to pay a $30 copayment for physical therapy. Physical therapy falls 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 on February 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a skin abscess drainage performed on 
April 6, 2022. 
 
You asked the Plan to reduce the copayment for the abscess drainage. You say that you were seen in an office 
setting and should only have a $30 specialist 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 $325 
copayment per visit for surgery or services provided at an outpatient hospital or ambulatory surgical center.  
 
You have been asked to pay $82.70, which is less than the $325 copayment for the abscess drainage. The 
abscess drainage is considered a surgical procedure and 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 reduce the copayment for a skin abscess drainage performed on April 6, 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 Prolia. You say that Prolia is medically necessary. The Plan denied your 
request. The Plan says a trial of oral bisphosphonates and Zoledronic Acid is required before alternatives like 
Prolia 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 Prolia. Our reviewer says that Prolia is 
not medically necessary. Our physician reviewer found the patient has tried and failed Fosamax but there is no 
indication that the patient has tried and failed Zoledronic Acid.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiation treatments provided on April 5, 
2022. 
 
You asked the Plan to waive the copayment for radiation treatments. You say that you were unaware of the 
copayment amounts, and this will cause a financial hardship. 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 $60 
copayment for outpatient diagnostic tests.  
 
You have been asked to pay a $60 copayment for radiation treatments. Radiation treatments falls within the 
Outpatient Diagnostic 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 radiation 
treatments provided on April 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiation therapy (IMRT) provided on 
March 31, 2022. 
 
You asked the Plan to waive the copayment for radiation therapy (IMRT). You say that you were not aware of 
the copayments and you cannot afford to pay them. 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 $60 
copayment for Medicare-covered diagnostic radiology services (not including X-rays).  
 
 
  You have been asked to pay a $60 copayment for radiation therapy (IMRT). Radiation therapy (IMRT) 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 radiation therapy (IMRT) provided on March 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for radiation therapy treatment provided from 
March 9, 2022, to March 11, 2022. 
 
You asked the Plan to waive the copayments for the radiation treatment. You say that you were not aware of 
the copayments. 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 therapeutic radiology services.  
 You have been asked to pay a $60 copayment for each radiation treatment, for a total of $180. The radiation 
treatment 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 treatment provided from March 9, 2022, 
to March 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiation therapy treatment provided on 
February 28, 2022. 
 
You asked the Plan to waive the copayment for the radiation treatment. You say that you were not aware of the 
copayments. 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 therapeutic radiology services.  
 
You have been asked to pay a $60 copayment for the radiation treatment. The radiation treatment 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 radiation therapy treatment provided on February 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiation therapy on April 27, 2022. 
 
You asked the Plan to waive the copayment for radiation therapy. 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 $60 
copayment for Medicare-covered therapeutic radiology services. Covered services include but are not limited 
to other outpatient diagnostic tests.  
 
You have been asked to pay a $60 copayment for radiation therapy. 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 copayment for radiation therapy on April 27, 2022.