Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a walker provided on October 21, 2021. 
 
You asked the Plan to waive the coinsurance for a walker. You say that you were informed the item would be 
covered at 100%. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for Medicare-covered durable medical equipment (DME) and related supplies. The allowed 
amount of the claim is $40.92, resulting in a coinsurance amount of $8.18 ($40.92 x 20%). 
 
You have been asked to pay $8.18 for a walker. A walker falls 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 coinsurance for a walker 
provided on October 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an arthrocentesis provided on October 19, 
2021, and January 26, 2022. 
 
You asked the Plan to waive the copayments for an arthrocentesis. You say that you had no knowledge of your 
copayment prior to the service. 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 $300 
copayment for surgery services at an outpatient hospital.  The record shows these claims were approved, and you have a cost sharing amount. You have been asked to 
pay a $300 copayment for each arthrocentesis on October 19, 2021, and January 26, 2022. An arthrocentesis 
falls 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 copayments 
for an arthrocentesis provided on October 19, 2021, and January 26, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound of the upper extremity 
provided on December 17, 2021. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you should not be liable for this 
copayment because you had to have the test done after getting a possible hematoma from the needle in the 
emergency room. 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 $100 
copayment for diagnostic radiology services, including ultrasounds.  
 
 You have been asked to pay a $100 copayment for an ultrasound. An ultrasound falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for an ultrasound of the upper extremity provided on December 17, 2021.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cataract removal procedure performed on 
December 8, 2021. 
 
You asked the Plan to waive the copayment for the cataract surgery. You say that you were not aware of the 
copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment per day for outpatient procedures.  
 
You have been asked to pay a $100 copayment for the cataract surgery. The cataract surgery 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 cataract removal 
procedure performed on December 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for eye injections (bimatoprost) provided 
from September 8, 2021, to September 24, 2021. 
 
You asked the Plan to waive the coinsurance for the bimatoprost injections. You say that you cannot afford the 
charges. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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 Part B drugs. 
 
 
 
 Drug Allowed Amount 20% Coinsurance 
Bimatoprost  September 8, 2021 $2,062.60 $412.52 
Bimatoprost  September 24, 2021 $2,062.60 $412.52 
Total:  $825.04 
 
You have been asked to pay $825.04, which is 20% of the allowed amount for the bimatoprost injections. The 
bimatoprost 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 eye injections (bimatoprost) provided from September 8, 2021, to 
September 24, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued home health skilled nursing services. 
 
You asked the Plan to pre-approve continued home health skilled nursing services. You did not provide a 
specific argument with your appeal request. The Plan denied your request. The Plan says additional home 
health services are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 continued home health skilled nursing 
services. Our reviewer says that continued home health skilled nursing services are not medically necessary. 
Our physician reviewer found the documentation doesnt support that you require additional skilled nursing 
services to provide treatment that is medically necessary. You do not require additional skilled nursing services 
to effectively provide treatment, care, and/or services in order to improve your condition, perform a 
maintenance program to maintain your condition and/or prevent deterioration.  You have been medically stable 
without any recent exacerbations of chronic medical problems or hospitalizations.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued home health skilled nursing services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve continued home health skilled nursing services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Fulphila 
 
You asked the Plan to pre-approve Fulphila. You say that this drug is medically necessary for the patient. The 
Plan denied your request. The Plan says that there is no medical need for this drug because the patient is low-
risk. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Fulphila. Our reviewer says that this 
drug is medically appropriate for this patient. Our physician reviewer found the use of growth factor support is 
recommended if the risk of neutropenic fever is >20%. Given the regimen, age of >65, and the ongoing 
COVID-19 pandemic, the risk of neutropenic fever for this patient is >20% and criteria for the use of Fulphila 
would be met.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Fulphila have been met. Therefore, we decided that the Plan has to pre-approve 
Fulphila  
 
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 Fluorouracil, Leucovorin, Nivolumab, and Irinotecan 
Liposome. 
 
You asked the Plan to pre-approve Fluorouracil, Leucovorin, Nivolumab, and Irinotecan Liposome. You say 
that these drugs are medically necessary for this patient because she has developed progressive neuropathy that 
is limiting her daily activities. The Plan denied your request. The Plan says these drugs are considered 
experimental for the patient's condition. 
 
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 Fluorouracil, Leucovorin, Nivolumab, 
and Irinotecan Liposome. Our reviewer says that Fluorouracil, Leucovorin, Nivolumab, and Irinotecan 
Liposome are not medically necessary for this patient. Our physician reviewer found these drugs are not Food 
and Drug Administration (FDA)-approved for the patient's diagnosis and the use of these drugs do not appear 
in an approved medical journal.  The use of these drugs for the patient's condition is not supported or recommended in any of the Centers for 
Medicare and Medicaid services-approved compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Fluorouracil, Leucovorin, Nivolumab, and Irinotecan Liposome have not been 
met. Therefore, we decided that the Plan does not have to pre-approve Fluorouracil, Leucovorin, Nivolumab, 
and Irinotecan Liposome.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the abdomen and pelvis. 
 
You asked the Plan to pre-approve the CT scan. You say that this CT scan is needed to evaluate the patient's 
recent weight loss. The Plan denied your request. The Plan says that weight loss is not a medical reason for this 
CT scan. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the CT scan. Our reviewer says that the 
requested CT scan is medically necessary. Our physician reviewer found the patient has a history of perforated 
viscous, bowel resection and abdominal wall hematoma.  All of these facts together with a rapid 40-pound 
weight loss provide indications for CT of the abdomen and pelvis in a patient who is not a good candidate for 
ultrasound sucb as this patient with a body mass index over 50. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) scan of the abdomen and pelvis.  
 
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 home health services provided on November 1, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not 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 home health services provided on November 1, 
2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment provided on September 27, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for medication assisted treatment. You say that you obtained authorization for the 
wrong code. The Plan denied your request. The Plan says the services were provided out-of-network and were 
not 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 medication assisted treatment provided on 
September 27, 2021 by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on April 14, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that the provider is in-network. The Plan denied 
your request. The Plan says the services were provided out-of-network and were not 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 home health services provided on April 14, 2021 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the harvesting and injection of platelet rich plasma services 
you received on January 29, 2022. 
 
You asked the Plan to pay for the harvesting and injection of platelet rich plasma services. You say that this 
service was needed to regenerate nerves. The Plan denied your request. The Plan says this treatment is 
considered experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 pay for the harvesting and injection of platelet rich 
plasma services. Our reviewer says that he is harvesting, and injection of platelet rich plasma services were not 
considered medically reasonable and necessary in this case.  
 Our physician reviewer found there is insufficient medical evidence at this time to demonstrate that platelet 
rich plasma treatment is medically reasonable and necessary for the treatment of Parsonage-Turner syndrome. 
The use of platelet rich plasma in this case may be considered experimental/investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the harvesting and injection of platelet rich plasma services have not been met. 
Therefore, we decided that the Plan does not have to pay for the harvesting and injection of platelet rich plasma 
services you received on January 29, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on September 9, 
2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that the ultrasound code charged by the 
provider was not specific. The Plan denied your request. The Plan says the copayment amount 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 $155 
copayment for Medicare-covered radiological diagnostic services, not including X-rays, performed in a 
physician's office or at a free-standing facility (such as a radiology center or medical clinic). The diagnostic 
radiology services require specialized equipment beyond standard X-ray equipment and must be performed by 
specially trained or certified personnel. Examples include, but are not limited to, ultrasounds.  
 
You have been asked to pay a $123.50 copayment for the ultrasound, which is less than the Plan's EOC 
documented $155 copayment for ultrasounds. An ultrasound falls within the Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
the ultrasound provided on September 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for wound care supplies provided on 
September 29, 2021. 
 
You asked the Plan to waive the coinsurance for the wound care supplies. You say that the nurse informed you 
that they would be fully covered. The Plan denied your request. The Plan says the correct coinsurance was 
applied. 
 
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 durable medical equipment (DME) and supplies, including wound care supplies.  
 
You have been asked to pay $22.60, which is 20% of the allowed amount for the wound care supplies ($113.00 allowed amount x 20% coinsurance = $22.60). The wound care supplies 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 coinsurance 
for wound care supplies provided on September 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomographic angiography 
(CTA) provided on June 17, 2021. 
 
You asked the Plan to waive the copayment for the CTA. You say that you cannot afford the copayment. The 
Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for each diagnostic imaging service, including CT scans.  
 
You have been asked to pay $191.08, which is less than the $275 copayment for the CTA. The CTA falls 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a computed tomographic angiography (CTA) provided on June 17, 
2021.