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

 
We decided that the Plan does not have to waive the copayment for a breast biopsy (19081) provided on 
October 26, 2021. 
 
You asked the Plan to waive the copayment for the breast biopsy. You say that the services should be covered 
as you disagree with the charges and were not made aware of them beforehand. The Plan denied your request. 
The Plan says the cost-sharing applied 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 $310 
copayment for Outpatient hospital services.  
 
 
  You have been asked to pay a $310 copayment for the breast biopsy. Biopsies fall within the Outpatient 
hospital 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 a breast biopsy 
(19081) provided on October 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6. 
 
You asked the Plan to pre-approve a Dexcom G6. You say that the item is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Dexcom G6 have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom 
G6.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an outpatient surgical procedure 
performed on November 16, 2021, and November 17, 2021. 
 
You asked the Plan to waive the coinsurance for the outpatient surgical procedure. You say that the services 
should be covered as you disagree with the charges and were not made aware of them beforehand. The Plan 
denied your request. The Plan says the coinsurance applied correctly based on the services 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 20% 
coinsurance for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay a 20% coinsurance for the outpatient surgical procedure (total allowed is $ 
23,669.69 x 20% = $4,733.94). This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an outpatient surgical 
procedure performed on November 16, 2021, and November 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on December 16, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you did not comprehend the procedure or format and 
are requesting a leniency in this manner. The Plan denied your request. The Plan says the services were 
provided by a non-contracted provider, and after review, it was determined that there are no records of a 
referral from the member's primary care physician (PCP) to the primary medical group (PMG) prior to services 
being rendered on December 16, 2021. 
 
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 (99214) provided on December 16, 
2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Trodelvy. 
 
You asked the Plan to pre-approve Trodelvy. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says that the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Trodelvy. Our reviewer says that the 
requested drug is medically reasonable and necessary. Our physician reviewer found the enrollee is a 78-year-
old male with right breast cancer, stage IIIA. In this case, Trodelvy is FDA-approved for the enrollee's 
condition as the patient has triple negative breast cancer and has received 2 prior lines of therapy (gemcitabine 
and a drug regimen including cyclophosphamide, methotrexate, and fluorouracil). The requested drug is 
medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Trodelvy have been met. Therefore, we decided that the Plan has to pre-approve 
Trodelvy.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a power wheelchair (K0856) provided on 
March 9, 2021. 
 
You asked the Plan to waive the copayment for the power wheelchair. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the coinsurance applied 
correctly based on the services 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 30% 
coinsurance for out-of-network Durable medical equipment (DME) and related supplies.  
 
 
  You have been asked to pay a 30% coinsurance for out-of-network for the power wheelchair (allowed is 
$853.64 x 30% = $256.09). Power wheelchairs fall within the Durable medical equipment (DME) and related 
supplies benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for a power wheelchair 
(K0856) provided on March 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit (99342) and the debridement of nails (11721) 
provided on July 2, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a home visit and the debridement of nails. You say that the provider does accept 
Medicare and as participating Medicare provider the provider should be reimbursed Medicare rates. The Plan 
denied your request. The Plan says this provider is not a network provider with the Plan, and they have also 
determined that these services are not urgent or emergent, nor were they approved in advance. 
 
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 a home visit (99342) and the debridement of nails 
(11721) provided on July 2, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a power wheelchair and accessories to be provided by an OON provider. 
You say that the services are necessary. The Plan denied your request. The Plan says there are in-network 
providers that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a power wheelchair and accessories to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services provided 
on August 7, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the trip was related 
to COVID-19. The Plan denied your request. The Plan says the enrollee was 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $265 copayment per date of service for ground ambulance transportation.  
 
The records provided list the diagnosis as COPD. Therefore, the enrollee was asked to pay a $265 copayment 
for the ambulance transportation. The ambulance transportation falls within the Ambulance Services benefit category. This means that the enrollee was 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 copayment for ambulance transportation services provided 
on August 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an excision of eyelid lesion (68110) 
provided on October 15, 2021. 
 
You asked the Plan to waive the copayment for the excision of eyelid lesion. You say that the services should 
be covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing 
applied correctly based on the services 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 $295 
copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
 
  You have been asked to pay a $176.16 copayment for the excision of an eyelid lesion, which is less than the 
standard $295. Excision of eyelid lesions fall 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 excision of eyelid lesion (68110) provided on October 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (36415, 80061, 82043, 82570, 83036) 
provided on May 24, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that while you make your best effort to adhere to 
the authorization policy, there are occasional situations that prevent you from meeting the guidelines as 
required. You also say the provider followed all necessary steps to treat the patient with services to enhance the 
patient's immediate and long-term being. You also say that authorization was not intended to be a cost 
containment system. The Plan denied your request. The Plan says the rendering provider is a non-participating 
provider, there is no referring provider involved in these services, and the Plan did not authorize any services 
for this provider nor for the facility. 
 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 (36415, 80061, 82043, 82570, 
83036) provided on May 24, 2021, 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 hospital provided from 
October 30, 2021, to November 6, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services 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 $360 
copayment per day for days 1-5 of Inpatient hospital care.  
 
 
  You have been asked to pay a $1,440 copayment for 4 days of inpatient hospital care ($360 x 4 = $1,440). 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 hospital provided from October 30, 2021, to 
November 6, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for non-emergent ground transport (A0426, 
A0425) provided on July 6, 2021. 
 
You asked the Plan to waive the copayment for non-emergent ground transport. You say that the ambulance 
ride was a transfer between hospitals. You also say you were concerned about the cost, but they said it should 
be covered since it was a transfer from one hospital to the next. 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 $350 
copayment for each Medicare-covered one-way trip via ground ambulance.  
 
 You have been asked to pay a $350 copayment for non-emergent ground transport. Non-emergent ground 
transport 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. The record shows that this service was covered, but there 
is a cost sharing responsibility for the enrollee. 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 
non-emergent ground transport (A0426, A0425) provided on July 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgical procedure (66986) 
provided on December 16, 2021. 
 
You asked the Plan to waive the copayment for the outpatient surgical procedure. You say that the services 
should be covered as you disagree with the charges. The Plan denied your request. The Plan says the 
copayment applied correctly based on the services 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $200 copayment for Outpatient surgery, including services provided at hospital outpatient facilities 
and ambulatory surgical centers*.  
 
 
  The enrollee has been asked to pay a $200 copayment for the outpatient surgical procedure. 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 copayment for an outpatient surgical procedure (66986) provided on December 16, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does require physical therapy and occupational therapy services, but the medical records provided do not 
clarify why the enrollee requires an intensive inpatient rehabilitation therapy program. Medically necessary 
services can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (93656) provided on 
July 21, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be 
covered in full as it was a follow-up visit. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. These services are ineligible to be considered a follow-up as they fall 
out of the global benefit period. 
 
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 Physician/Practitioner services, including doctor's office visits.  
 
 
  You have been asked to pay a $35 copayment for the specialist office visit. Specialist 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 a specialist office visit (93656) provided on July 21, 2021.