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

 
We decided that the Plan does not have to waive the cost sharing for Part B drugs and magnetic resonance 
imaging (MRI) on March 17, 2022, to April 15, 2022. 
 
You asked the Plan to waive the cost sharing for Part B drugs and MRI. 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 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. You must 
pay $150 copayment per day, per provider, for Medicare-covered diagnostic radiology services. Covered 
services include but are not limited to diagnostic radiology services (for example, MRI, CT).  
 
On March 17, 2022, 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 $10,146.80 and the allowed amount is $3,484.41. 
$3,484.41 x 20% = $696.88. $11.58 + $696.88 = $708.46. On April 15, 2022, the provider billed in the amount 
of $23.92 and the allowed amount is $8.21. $8.21 x 20% = $1.64. The provider also billed in the amount of 
$171.22 and the allowed amount is $58.80. $58.80 x 20% = $11.76. $1.64 + $11.76 + $150 = $163.40. $708.46 
+ $163.40 = $871.86. Therefore, results in the total cost sharing amount of $871.86. 
 
You have been asked to pay a 20% coinsurance for Part B drugs and a $150 copayment for MRI. Part B drugs 
and MRIs fall within the Medicare Part B prescription drugs and 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 cost sharing for Part B 
drugs and magnetic resonance imaging (MRI) on March 17, 2022, to April 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Part B drugs on May 06, 2022. 
 
You asked the Plan to waive the coinsurance for Part B drugs. 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 Medicare Part B prescription drugs. 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 
$5,880 and the allowed amount is $1,957.20. $1,957.20 x 20% = $391.44. Therefore, results in the total cost 
sharing amount of $391.44.  
 
 
 
 You have been asked to pay a 20% coinsurance for Part B drugs. Part B drugs 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 drugs on 
May 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided March 2, 2022 to March 30, 
2022  
 
You asked the Plan to pay for the outpatient services. You say that the services were 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the outpatient services are not supported in the medical record. Specifically, there were multiple 
emergency room visits in the same day at the same revenue center that were billed without Condition code G0. 
Based on this information, we decided that Medicare rules for coverage of the outpatient services have not been 
met. Therefore, we decided that the Plan does not have to pay for outpatient services provided March 2, 2022 
to March 30, 2022
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the ambulance treatment without transport 
provided on June 03, 2022. 
 
You asked the Plan to waive the deductible for the ambulance treatment without transport. You say that you do 
not feel the charges were worth the services received. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $450 
deductible for ambulance services. 
 
You have been asked to pay a $450 deductible for the ambulance treatment without transport. This item/service 
falls within the ambulance services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan.  Therefore, we decided that the Plan does not have to waive the deductible for 
the ambulance treatment without transport provided on June 03, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home infusion therapy of intravenous (IV) Ocrevus. 
 
You asked the Plan to pre-approve home infusion therapy of IV Ocrevus. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that an external infusion pump is covered under certain 
circumstances. 
 
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 home infusion therapy of IV Ocrevus. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the provider 
stated the drug will be buy and bill. A request for additional information by the health plan was returned from 
the provider's office stating this will be administered via home infusion using a free drug program. Ocrevus is 
not eligible for coverage under CMS part B benefits in the home infusion setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home infusion therapy of IV Ocrevus have not been met. Therefore, we decided 
that the Plan does not have to pre-approve home infusion therapy of intravenous (IV) Ocrevus.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital visit provided on March 
28, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital visit. You say that you understand the claims 
were processed incorrectly and your share of the cost does not reflect your actual benefit. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for inpatient hospital care. 
 
You have been asked to pay a $250 copayment for inpatient hospital visit. This item/service 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 visit provided on March 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 
You asked the Plan to pre-approve Vabysmo. 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 Vabysmo. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of diabetic macular edema and moderate non-proliferative diabetic 
retinopathy. The documentation does not support that the enrollee has tried and failed Lucentis. The 
documentation does not support that Lucentis 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 Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram provided on May 10, 
2022. 
 
You asked the Plan to waive the copayment for an electrocardiogram. You say that you feel you shouldnt have 
any cost share applied to this claim because it was a pre-operation visit. The Plan denied your request. The Plan 
says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $12 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $12 copayment for an electrocardiogram. This item/service falls within the 
outpatient diagnostic test benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan.  Therefore, we decided that the Plan does not have to waive the copayment for an 
electrocardiogram provided on May 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek test strips (A4253).  
You asked the Plan to pre-approve the Accu-Chek test strips. You say that you have an Accu-Chek glucometer 
and would prefer to continue using Accu-Chek. The Plan denied your request. The Plan says the request test 
strips are not a covered brand. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. 
 
We looked at the file and Medicare rules. The requested Accu-Chek brand test strips are not listed as a covered 
brand. No medical documentation was provided to show that this brand would be unsuitable to the enrollee. 
Based on this information, we decided that Medicare rules for coverage of the Accu-Chek test strips have not 
been met. Therefore, we decided that the Plan does not have to pre-approve Accu-Chek test strips (A4253).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray of the thoracic spine (72070), an injection of 
propofol (J2704), and the implantation of a neurostimulator lead (C1778) and electrode (63650) provided on 
April 5, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a surgical spinal procedure. You say that the provider extended treatment in good 
faith based on the medical necessity for hospitalization. The Plan denied your request. The Plan says a prior 
authorization is required but there is no record of an attempt to obtain one. The Plan also says that there was no 
referral for the enrollee to see the out-of-network provider. Furthermore, the Plan could not confirm medical 
necessity with the documentation received from the out-of-network facility. The Plan attempted to obtain 
additional information from the facility, but the attempt was unsuccessful. 
 
 
 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 x-ray of the thoracic spine (72070), an injection 
of propofol (J2704), and the implantation of a neurostimulator lead (C1778) and electrode (63650) provided on 
April 5, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for emergency services and ambulance on 
May 11, 2022, May 13, 2022. 
 
You asked the Plan to waive the copayments for emergency services and ambulance. 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 $90 
copayment for emergency room. Emergency care refers to services that are furnished by a provider qualified to 
furnish emergency services and needed to evaluate or stabilize an emergency medical condition. You must pay 
a $270 copayment per date of service regardless of the number trips for ground ambulance. Covered ambulance 
services include fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that 
can provide care only if they are furnished to a member whose medical condition is such that other means of 
transportation could endanger the person's health or if authorized by the plan. $90 + $270 = $360. Therefore, 
results in the total cost sharing amount of $360.  
 
You have been asked to pay a $90 copayment for emergency services and a $270 copayment for ambulance. 
Emergency services and ambulance falls within the Emergency care and 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 copayments for emergency services and ambulance on May 11, 2022, May 
13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist visit provided on March 24, 
2022. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that you are requesting the services 
to be paid. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for physician/practitioner services, including doctors office visits (specialist visits). 
 
You have been asked to pay a $25 copayment for the specialist visit. This item/service falls within the 
physician/practitioner services, including doctors office visits (specialist 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 the specialist visit provided on March 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and coinsurance for an out-of-network (OON) 
specialist office visit provided on May 25, 2022. 
 
You asked the Plan to waive the deductible and coinsurance for the out-of-network (OON) specialist visit. You 
say that the provider should be considered in-network. The Plan denied your request. The Plan says you were 
charged this cost sharing 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 $250 deductible which applies to certain items and services. 
 
Your contract with the Plan also clearly says that you must pay a 50% coinsurance for provider and 
professional services at an out-of-network specialist's office, after the deductible is met. 
 
The out-of-network (OON) specialist visit falls within the Physician/Practitioner Services, Including Doctor's 
Office Visits 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 out-of-network (OON) specialist visit was received on May 25, 
2022.  
 
The file shows that on the date of service, you had $52.27 remaining to meet your deductible. This amount was 
applied first, leaving a remaining allowed amount of $144.24. Of this amount, the 50% coinsurance of $72.12 
was applied. The total for the visit is $124.39. Please note that the Plan also verified the provider is not a 
network provider. Therefore, we decided that the Plan does not have to waive the deductible and coinsurance 
for an out-of-network (OON) specialist office visit provided on May 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an eye appointment provided on June 10, 
2022. 
 
You asked the Plan to reduce the copayment for an eye appointment. You say that I should not have a 
copayment for this service. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for vision care. 
 
You have been asked to pay a $25 copayment for an eye appointment. This item/service falls within the vision 
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 reduce the copayment for an eye appointment provided on 
June 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the infusion services provided on January 
05, 2022, to January 13, 2022. 
 
You asked the Plan to waive the copayment for the infusion services. You say that you did not have surgery, 
and the EOC is unclear about infusion. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $590 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers (outpatient hospital facility visit). 
 
You have been asked to pay a $590 copayment for the infusion services. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
(outpatient hospital facility visit) 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. Per the EOC, there is $295 copayment for each outpatient hospital visit. The file shows two infusions provided at an outpatient hospital facility. The total for both services is $590 ($295 
copayment x 2 visits). Therefore, we decided that the Plan does not have to waive the copayment for the 
infusion services provided on January 05, 2022, to January 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the out-of-network (OON) anesthesia 
services provided on May 12, 2022. 
 
You asked the Plan to waive the deductible for the out-of-network (OON) anesthesia services. You say that you 
were not aware that the provider was out-of-network. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $1,000 
deductible for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $1,000 deductible for the out-of-network (OON) anesthesia services. This 
item/service 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. The file shows that the Plan verified the provider is not a network provider. Therefore, we decided that the Plan does not have to waive the deductible for the out-of-network (OON) anesthesia services 
provided on May 12, 2022.