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

 
We decided that the Plan does not have to waive the coinsurance for Part B injection on April 06, 2022. 
 
You asked the Plan to waive the coinsurance for Part B injection. 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 20% 
coinsurance for each Medicare-covered Part B drug obtained in a providers office or outpatient setting. These 
drugs are covered under Part B of Original Medicare. Members of our plan receive coverage for these drugs 
through our plan. Covered drugs include drugs that usually arent self-administered by the patient and are 
injected or infused while you are getting physician, hospital outpatient, or ambulatory surgical center services. 
The provider billed in the amount of $168.54 and the allowed amount is $57.88. $57.88 x 20% = $11.58. The 
provider also billed in the amount of $4,458.59 and the allowed amount is $1,531.08. $1,531.08 x 20% = 
$306.22. $11.58 + $306.22 = $317.80. Therefore, results in the total cost sharing amount of $317.80. 
 
 You have been asked to pay a 20% coinsurance for Part B injection. Part B injections fall within the Medicare 
Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for Part B 
injection on April 06, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the genetic testing provided on March 9, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has denied payment for the testing in question because they 
state they reached out to the providers office and confirmed that testing was not ordered. This stands in 
opposition to the signed order form and medical records that were submitted. The Plans submitted evidence 
that testing was not ordered is not supported in this case. Therefore, we decided that the Plan has to pay for the 
genetic testing provided on March 9, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an inpatient stay provided from June 1, 
2022, to June 6, 2022. 
 
You asked the Plan to waive the copayments for an inpatient stay. You say that you believe you should have 
only been inpatient for two to three days. 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 $325 
copayment per day for the first five days of in-network inpatient hospital care.  
 
You have been asked to pay $1,625 for an inpatient stay ($325 x 5). 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 copayments for an inpatient stay provided 
from June 1, 2022, to June 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiation therapy provided on March 21, 
2022. 
 
You asked the Plan to waive the copayment for radiation therapy. You say that you were unaware that you 
would have a copayment for the services and cannot afford to pay them. The Plan denied your request. The 
Plan says the copayment applied 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.  
 
 
  You have been asked to pay a $60 copayment for radiation therapy. Radiation therapy falls within the 
Outpatient Diagnostic Test 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 provided on March 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI scan of upper spinal canal without contrast. 
 
You asked the Plan to pre-approve an MRI scan. You say that the MRI scan of upper spinal canal is medically 
necessary. The Plan denied your request. The Plan says the MRI does not meet medical necessity because the 
reports Radiculopathy, at least 6 weeks of conservative management/care, and the enrollee has not had physical 
therapy for their condition. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI scan. Our reviewer says that 
the MRI of the spine is not medically needed at this time. Our physician reviewer found that a 6-week trial of 
conservative measures to include physical therapy is needed at this time. 
 
  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 MRI scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an MRI scan of upper spinal canal without contrast.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay more for the gym membership you purchased on March 19, 2022. 
 
You asked the Plan to pay more for the gym membership. You say that you purchased this membership while 
you were still enrolled, so you're entitled to the full $150 you are requesting. The Plan denied your request. The 
Plan says that because you disenrolled from the Plan on March 31, 2022, you are only entitled to partial 
reimbursement. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
up to $250 per calendar year. There is nothing in the Plan's contract document that says that this benefit will be 
reduced or pro-rated if you leave the Plan before a year's gym membership is exhausted. Therefore, we decided 
that the Plan has to pay more for the gym membership you purchased on March 19, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 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 Euflexxa. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has bilateral knee pain related to osteoarthritis. This diagnosis is confirmed with imaging 
studies. The enrollee has failed conservative treatment. The documentation does not support that the enrollee 
has tried and failed Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-One. The documentation does not 
support that Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-One would likely be less effective and/or 
likely have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested 
drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on May 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the OON medical services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
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 provider in this case is not a network provider with the Plan. 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 medical services provided on May 11, 2022, by an out-of-
network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy on October 21, 2021, to 
October 28, 2021. 
 
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 $40 
copayment for physical therapy at outpatient hospital. 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). There were 2 visits. $40 x 2 = $80. Therefore, results in the total cost 
sharing amount of $80.  
 
 
 
 You have been asked to pay a $40 copayment for each physical therapy visit. 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 October 21, 2021, to October 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for office visit on August 19, 2021. 
 
You asked the Plan to waive the coinsurance for office visit. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing the enrollee is 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a 30% coinsurance per visit in a certified ambulatory surgical center or hospital outpatient 
department. Covered services include medically-necessary medical care or surgery services furnished in a 
physicians office, certified ambulatory surgical center, hospital outpatient department, or any other location. 
Consultation, diagnosis, and treatment by a specialist. The provider billed in the amount of $957.30 and the 
allowed amount is $514.29. $514.29 x 30% = $154.29. Therefore, results in the total cost sharing amount of 
$154.29. 
 
 
 The enrollee has been asked to pay a 30% coinsurance for office visit. Office visits fall within the 
Physician/Practitioner services, including doctor's office visit 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 office visit on August 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection provided from January 11, 
2021, to May 24, 2022. 
 
You asked the Plan to waive the copayment for an injection. You say that you did not have a $50 copayment 
for this injection in 2021, and you feel you should not have to pay that copayment in 2022. The Plan denied 
your request. The Plan says the copayment that was 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 $50 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay a $50 copayment for an injection. An 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 the copayment for an injection provided from 
January 11, 2021, to May 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 2, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that this patient is an established patient with you 
and presented for care on May 2, 2022. You also say that this should follow under the continuity of care and a 
payment should be made. The Plan denied your request. The Plan says there is no documentation to show that 
this member was referred to this non-contracted provider by a contracted provider, as well as no indication any 
attempt was made to obtain prior authorization for the out-of-network 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 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 May 2, 2022, by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided from November 
1, 2021, to November 8, 2021. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you cannot afford this 
copayment. 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 $240 
copayment per day for days 1 to 7 for inpatient hospital care.  
 
You have been asked to pay a $1,680 copayment for a 7 day inpatient stay ($240 x 7 days = $1,680). 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 November 1, 2021, to November 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on May 23, 2022, to 
May 26, 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 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 $390 
copayment for each day in a hospital for the first five days; you pay $0 for each day after day 5 for each 
inpatient stay. 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. There were 3 days. $390 x 3 = 
$1,170. Therefore, results in the total cost sharing amount of $1,170.  
 
You have been asked to pay a $390 copayment each day for inpatient hospital stay. Inpatient hospital 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 
inpatient hospital stay on May 23, 2022, to May 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic inserts (A5514-RT-KX and A5514-LT-KX) 
provided on April 16, 2022. 
 
You asked the Plan to pay for codes A5514-RT-KX and A5514-LT-KX. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 
as billed. 
 
The Plan must follow Medicare rules. The rules say that diagnosis codes must be billed with the most precise 
code that most fully explains the narrative description of the symptom or diagnosis. 
 
We looked at the file and Medicare rules. The file shows that the diabetic inserts were billed with one or more 
diagnosis codes that were inappropriately coded. Medicare rules say that some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. It is not appropriate to report 
unspecified when a more specific diagnosis code is available. Therefore, we decided that the Plan does not 
have to pay for the diabetic inserts (A5514-RT-KX and A5514-LT-KX) provided on April 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on April 18, 2022. 
 
You asked the Plan to waive the copayment for office visit. 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 $35 
copayment for provider and professional services at specialists office. Covered services include medically-
necessary medical care or surgery services furnished in a physicians office, certified ambulatory surgical 
center, hospital outpatient department, or any other location and consultation, diagnosis, and treatment by a 
specialist. 
 
 
 
 
 You have been asked to pay a $35 copayment for office visit. Office visits fall within the Physician/Practitioner 
services, including doctor's office visits benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for office visit on April 18, 2022.