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

 
We decided that the Plan does not have to waive the cost share for the denosumab injection and the specialist 
office visit provided on December 14, 2022. 
 
You asked the Plan to waive the cost share for the injection and the specialist office visit. You say that you 
cannot afford this cost share. 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 20% 
coinsurance for Medicare Part B drugs. Your contract with the Plan also clearly says that you must pay a $40 copayment for each Medicare-covered visit to a specialist. 
 
You have been asked to pay $270.12 coinsurance, which is 20% of the allowed amount for the denosumab 
injection ($1,350.60 allowed amount x 20% =$270.12). This item/service falls within the Medicare Part B 
prescription drugs benefit category. You have also been asked to pay a $14.82 copayment, which is less than 
the standard $40 copayment for the specialist office visit. This item/service 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 cost share for the denosumab injection and the specialist office visit provided on December 14, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's medical management and rehabilitation 
needs require an IRF stay and close physician supervision, and you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the requested IRF admission 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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for lower extremity cellulitis. The enrollees medical problems are stable, and there are 
no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the enrollee may have a need for physical therapy and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the urology specialist office visits 
provided from June 14, 2022, to December 1, 2022, and the lab services provided on December 1, 2022. 
 
You asked the Plan to waive the copayments for the office visits and lab services. You say that these were all 
follow-up services to a previous procedure. 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 $35 
copayment for each in-network specialist office visit. Your contract also clearly says that you must pay a $10 copayment for in-network lab services. 
 
You have been asked to pay up to a $35 copayment for each office visit. These items/services fall within the 
physician/practitioner services benefit category. You have also been asked to pay up to a $10 copayment for 
the lab services. This item/service falls within the outpatient diagnostic tests and therapeutic 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 the urology specialist office visits provided 
from June 14, 2022, to December 1, 2022, and the lab services provided on December 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the medical supplies provided on October 
18, 2022. 
 
You asked the Plan to waive the coinsurance for the medical supplies. You say that you were not given enough 
information about how this claim was processed. 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 20% coinsurance for in-network medical supplies.  
 
You have been asked to pay 20% coinsurance for the medical supplies. However, due to meeting your out-of-
pocket maximum during this claim you have only been asked to pay $160, which is less than the standard 20% 
coinsurance for the medical supplies. These items/services fall within the outpatient diagnostic tests and 
therapeutic 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 coinsurance for the medical supplies 
provided on October 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the pembrolizumab drug injection 
provided on November 18, 2022. 
 
You asked the Plan to waive the coinsurance for the drug injection. You say that you think there is a mistake 
with this coinsurance amount. 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 20% coinsurance for in-network Medicare Part B drugs.  
 
The record shows your out-of-pocket maximum was met during the processing of this claim. You have been 
asked to pay $3,280, which is less than the standard 20% coinsurance for the drug injection. This item/service 
falls within the Medicare Part B 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 
the pembrolizumab drug injection provided on November 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hospital observation services provided 
on November 29, 2022. 
 
You asked the Plan to waive the copayment for the hospital observation services. You say that you do not 
understand how you can be charged for observation services when you were so sick in the hospital. 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 $200 
copayment for outpatient hospital observations. 
 
You have been asked to pay a $200 copayment for the hospital observation services. This item/service falls 
within the outpatient hospital observations 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. However, since the allowed amount is less than the standard copayment, 
you only owe $85.74. Therefore, we decided that the Plan does not have to waive the copayment for the 
hospital observation services provided on November 29, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided from 
August 5, 2022, to August 18, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you think that the 
copayment is too high. 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 $325 
copayment per one-way trip for Medicare-covered ambulance services. 
 
 
 You have been asked to pay a $1500.30 copayment for the ambulance services because the allowed amount for 
each service is less than the $325 copayment. These items/services fall 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 the ambulance services provided from August 
5, 2022, to August 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the chemotherapy drugs and IV therapy 
provided on October 13, 2022. 
 
You asked the Plan to waive the coinsurance for the chemotherapy drug and IV therapy. You say that you 
would like the chemotherapy to be covered by the Plan. 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 20% 
coinsurance for each Medicare Part B chemotherapy drug.  
 
You have been asked to pay up to 20% for the chemotherapy drug. You have been asked to pay $50.38 
coinsurance, which 20% coinsurance of the allowed amount for the IV therapy ($251.89 allowed amount x 20% = $50.38). This item/service falls 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 the chemotherapy drugs and intravenous (IV) therapy 
provided on October 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital clinic visits provided 
by an in-network provider from November 8, 2022, to December 16, 2022, and the wound removal services 
provided by an in-network from December 29, 2022, to January 12, 2023. 
 
You asked the Plan to waive the copayment for the clinic visits and the wound removal services. You say that 
you cannot afford the copayment for these services. 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 $10 
copayment for all other in-network Medicare-covered outpatient hospital services, a $150 copayment for in-
network Medicare-covered outpatient hospital surgery services provided in 2022, and a $175 copayment for in-
network Medicare-covered outpatient hospital surgery services provided in 2023. 
 
You have been asked to pay a $60 copayment for the clinic visits ($10 x 6 visits = $60). These items/services 
fall within the outpatient hospital services benefit category. You have also been asked to pay a $500 copayment 
for the wound removal services ($150 + $175 + $175 = $500). These items/services fall within the outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit 
category.  
 
You have been asked to pay a total cost share of $560 for the clinic visits and the wound removal services ($60 
+ $500 = $560). 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 outpatient hospital clinic 
visits provided by an in-network provider from November 8, 2022, to December 16, 2022, and the wound 
removal services provided by an in-network from December 29, 2022, to January 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the oral device provided by an out-of-
network provider on May 23, 2022. 
 
You asked the Plan to waive the cost sharing for the oral device. You say that you would like the cost sharing 
to be lower. 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 says that you must pay the full cost for 
most covered services until you have paid the $1600 deductible, and the deductible applies to out-of-network 
durable medical equipment (DME) and related supplies. Your contract with the Plan also says that you must 
pay a 20% coinsurance, after the $1600 plan deductible, for each out-of-network Medicare-covered durable 
medical equipment item. 
 
You have been asked to pay a cost share of $1242.70 for the oral device ($1350 allowed amount - $1215.88 
deductible = $134.12) ($134.12 x .20 = $26.82 coinsurance) ($1215.88 deductible + $26.82 coinsurance = 
$1242.70). The item or service you asked the Plan to waive the cost sharing for was provided by an out-of-
network provider. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$1600 deductible which applies to durable medical equipment (DME) and related supplies. This cost sharing is 
a contractual obligation that had not been met at the time the oral device was provided on May 23, 2022. 
Therefore, we decided that the Plan does not have to waive the cost sharing for the oral device provided by an 
out-of-network provider on May 23, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy provided 
on December 01, 2022. 
 
You asked the Plan to waive the copayment for the esophagogastroduodenoscopy. You say that you have had 
the same procedure done before and did not have a copayment. 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 $325 
copayment for outpatient surgery, including services provided at ambulatory surgical centers. 
 
You have been asked to pay a $325 copayment for the esophagogastroduodenoscopy. This item/service falls within the outpatient surgery, including services provided at 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 the esophagogastroduodenoscopy provided on December 
01, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
October 28, 2022, to November 4, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you cannot afford this 
copayment. 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 $350 
copayment per day, for days 1 to 5 of in-network inpatient hospital care.  
 
You have been asked to pay a $350 copayment for days 1 to 5 of the inpatient hospital stay. You have not been 
charged for any additional days. 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 the inpatient hospital stay provided from October 28, 2022, 
to November 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
and supplies. 
 
 
 You asked the Plan to pre-approve the Freestyle Libre 2 CGM and supplies. You say that the CGM will 
provide better control of diabetes. The Plan denied your request. The Plan says the enrollee does not require 
insulin three or more times daily. 
 
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 
the Freestyle Libre 2 CGM and supplies have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the specialist office visit and retina 
imaging provided on December 5, 2022. 
 You asked the Plan to waive the copayments for the office visit and imaging services. You say that you were 
given incorrect information about your cost sharing. 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 $40 
copayment for in-network specialist office visits. Your contract with the Plan also clearly says that you must 
pay a $55 copayment for in-network diagnostic procedures or tests at an outpatient facility. 
 
You have been asked to pay a $40 copayment for the office visit. This item/service falls within the 
physician/practitioner services benefit category. You have also been asked to pay a $39.08 copayment, which is 
less than the standard $55 copayment for the imaging service. This item/service falls within the outpatient 
diagnostic tests and therapeutic services benefit category. You have been asked to pay a total of $79.08 ($40 
copayment + $39.08 copayment = $79.08). 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 the 
specialist office visit and retina imaging provided on December 5, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve an MRI of the lumbar spine. 
 
You asked the Plan to pre-approve the MRI. You say that you are requesting reconsideration for the denial of 
an MRI of the lumbar spine. The Plan denied your request. The Plan says that the request for an MRI of the 
lumbar spine is denied as not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI. Our reviewer says that the 
service is medically necessary and reasonable. Our physician reviewer found the enrollee has had extensive 
ankle surgery and persistent left plantar pain not explained by the MRI of the foot/ankle. On February 22, 2023, 
an electromyography (EMG) was done which revealed findings consistent with L5 and S1 radiculopathy. 
Based upon the workup, especially the positive EMG, the requested MRI of the lumbar spine should be 
approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI have been met. Therefore, we decided that the Plan has to pre-approve 
an MRI of the lumbar spine.  
 
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.