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

 
We decided that the Plan does not have to waive the cost share for denosumab injection and injection of drug 
provided on November 18, 2021. 
 You asked the Plan to waive the cost share for denosumab injection and injection of drug. You say that you 
were assured by the hospital that most of the cost would be covered. You say that the charges were billed as 
out-of-network. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for each Medicare-covered Part B drug and $275 copayment for Medicare-covered surgery or 
other services provided to you at an outpatient hospital, including but not limited to hospital or other facility 
charges and physician or surgical charges.  
 
You have been asked to pay $576.77, for the denosumab injection and injection of drug.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
November 18, 2021 Denosumab 
Injection 
$2,034.14 20% $508.54 
November 18, 2021 Injection of drug $68.23 $275 $68.23 
Total    $576.77 
 
The denosumab injection falls within the Medicare Part B Prescription Drugs benefits category and the 
injection of drug falls within the Outpatient Surgery and Other Medical Services Provided at Hospital 
Outpatient Facilities and Ambulatory Surgical Centers benefit category. The documentation shows the 
services were processed at the in-network benefit. 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 cost share for 
denosumab injection and injection of drug provided on November 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Subsequent Nursing Facility Care provided on December 8, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Subsequent Nursing Facility Care. You say that you would like to appeal the 
denial of the claim. The Plan denied your request. The Plan says the provider is out-of-network and it was 
determined these services can be received 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 Subsequent Nursing Facility Care provided on 
December 8, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit provided on January 3, 2022. 
 
You asked the Plan to waive the deductible for an office visit. You say that a specialist doctor visit is a 10% 
coinsurance and your share should be $7.82 The Plan denied your request. The Plan says the deductible applied 
correctly. 
 
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 a $100 deductible which applies to most Part B in-network and out-of-
network services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Physician/Practitioner 
Services including Doctors Office Visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $100 deductible which applies office visits. This cost sharing is a 
contractual obligation that had not been met at the time an office visit was received on January 3, 2022. 
Therefore, we decided that the Plan does not have to waive the deductible for an office visit provided on 
January 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
December 28, 2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that you should not be responsible for 
the bill. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $60 
copayment for out-of-network (OON) specialty care.  
 
The file shows that the Plan verified the providers out-of-network status. Therefore, you have been asked to 
pay a $60 copayment for the office visit. The office 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 the copayment for a 
specialist office visit provided on December 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 15, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and it was determined 
these services were not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on February 15, 2022 by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for plastic surgery provided by an out-of-
network provider on September 24, 2021. 
 
You asked the Plan to waive the coinsurance for the plastic surgery. You say that you are appealing and 
requesting a reconsideration of their cost-share charges. The Plan denied your request. The Plan says you have 
been asked to pay 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). The enrollees contract with the Plan clearly says that enrollees 
must pay 30% coinsurance for out-of-network surgery services.  
 
The enrollee has been asked to pay $513.74 which is 30% of the allowed amount for the plastic surgery. The 
allowed amount is $1,712.47. ($1,712.47 x 30% = $513.74). The plastic surgery falls within the Physician/ 
Practitioner services, including doctors office visits 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 plastic surgery provided by an out-of-network provider on September 24, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from 
September 21, 2021, to September 23, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital services. You say that the $500 is an insult to 
the patient considering the exorbitant itemized charges. The Plan denied your request. The Plan says you were 
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 $295 
copayment each day for days 1 to 5 for Medicare-covered hospital care.  
 
You have been asked to pay a total of $590 for 2 days of inpatient hospital services ($295 copayment x 2 days 
= $590). Inpatient hospital services fall 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 services provided from September 21, 2021, to 
September 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic injection of a drug into a vein 
provided from December 7, 2021, to December 28, 2021. 
 
You asked the Plan to waive the copayment for a diagnostic injection of a drug into a vein. You say that being 
that this treatment was recommended by two physicians and the provider did not itemize their billing 
description per event and only deducted the insurance mount paid off the total cost of treatment, you feel you 
should not be responsible for the lion share of the cost. The Plan denied your request. The Plan says you were 
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 $260 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital.  
You have been asked to pay $180, which is less than the $260 copayment for each diagnostic injection of a 
drug into a vein for a total of $720 ($180 copayment x 4 diagnostic injections = $720). A diagnostic injection 
of a drug into a vein 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 a diagnostic injection of a drug into a vein provided from December 7, 2021, to December 28, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on January 18, 
2022. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that your colonoscopy had nothing to 
do with your problem. You say that this was nothing you should be concerned about. The Plan denied your 
request. The Plan says you have been charged the correct copayment 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 for surgical service.  
 
 
 
 
  
You have been asked to pay a $325 copayment for a 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 provided on 
January 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for limited bilateral noninvasive physiologic 
studies of upper or lower extremity arteries provided on December 1, 2021. 
 
You asked the Plan to reduce the copayment for limited bilateral noninvasive physiologic studies of upper or 
lower extremity arteries. You say that this was a diagnostic lab procedure and should be a $30 copayment. The 
Plan denied your request. The Plan says you were 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 $160 
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a 
physician's office or at a free-standing facility for Outpatient Diagnostic Tests and Therapeutic Services 
and Supplies.   
You have been asked to pay $120.82, which is less than the $160 copayment for limited bilateral noninvasive 
physiologic studies of upper or lower extremity arteries. Limited bilateral noninvasive physiologic studies of 
upper or lower extremity arteries fall within the Outpatient Diagnostic Tests and Therapeutic Services 
and Supplies benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to reduce the copayment for limited bilateral 
noninvasive physiologic studies of upper or lower extremity arteries provided on December 1, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the office visit (99214) provided on February 9, 2022. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the copayment has been applied correctly 
to the service provided. 
 
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 enrollees must pay a $0 copay for each Primary Care Physician visit for a 
Medicare-covered service. Additionally, enrollees must pay a $40 copay for each Specialist office visit for 
Medicare-covered services. 
 
The Plan says you must pay a $40 copayment for a specialist office visit provided. Based on the Plan contract, 
however, you cannot be asked to pay more than a $0 copayment for this service. The documentation provided 
shows that you received this service from a physician assistant who works for a medical group that provides 
primary care physician services. Enrollees pay a $0 copayment for each primary care physician visit. 
Therefore, we decided that the Plan has to waive the copayment for the office visit (99214) provided on 
February 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an epidural injection.  
 
You asked the Plan to pay for an epidural injection. The Plan denied your request. The Plan says the Health 
Plan has not received the required clinical records to support the medical necessity of the service for the date of 
service requested. The records provided are undated and unsigned. There is insufficient documentation of 
response to prior injections. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an epidural injection provided on 
December 20, 2021 have been met. The Health Plan has not received the required clinical records to support 
the medical necessity of the service. Therefore, we decided that the Plan does not have to pay for an epidural 
injection provided on December 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer (J1439). 
 
You asked the Plan to pre-approve Injectafer. You say that this drug is medically reasonable and necessary. 
The Plan denied your request. The Plan says step therapy criteria have not been 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 Injectafer. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found The Plan requires a 
trial of Infed and Venofer before they will approve the requested drug. The case file does not contain 
documentation of trial and failure of Infed and Venofer. In addition, the documentation does not support that 
Infed and Venofer would likely be less effective, and/or would likely have adverse effects for the enrollee in 
this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer (J1439).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient dialysis services provided from 
August 3, 2021, to August 30, 2021. 
 
You asked the Plan to waive the coinsurance for outpatient dialysis services. You say that you want to know 
why you were charged differently on August 3, 2021, then all the other days. The Plan denied your request. 
The Plan says the coinsurance was applied correctly. You were only charged 15% coinsurance on August 3, 
2021, because you met your maximum out-of-pocket amount on that day and could only be held responsible 
for the amount up to the in-network maximum out-of-pocket 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 20% 
coinsurance for in-network Medicare-covered outpatient dialysis, self- dialysis training, certain home support 
services and home dialysis equipment and supplies.  
 
You have been asked to pay a total of $871.38 for outpatient dialysis services (allowed amount = $342 x 20% 
for 12 sessions and 15% for 1 session = $871.38). Outpatient dialysis services fall within the Services to treat 
kidney disease 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 outpatient dialysis 
services provided from August 3, 2021, to August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the injection(s), of an anesthetic agent(s) 
and/or steroid; transforaminal epidural, with imaging guidance (64483) provided on March 31, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copay for each Medicare-covered outpatient hospital facility visit.  
 
You have been asked to pay a $150 copayment for the Medicare-covered outpatient hospital facility visit 
provided. This means that you have been asked to pay the correct amount based on your contract with the Plan.  This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the injection(s), of an anesthetic agent(s) and/or 
steroid; transforaminal epidural, with imaging guidance (64483) provided on March 31, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on August 16, 
2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you took an emergency trip 
on August 16, 2021. You also say that you have been harassed for six months with monthly bills. 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 $280 
copayment for out-of-network ground ambulance services.  
 
You have been asked to pay a $280 copayment for ambulance services. Ambulance services 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 services 
provided on August 16, 2021.