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

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on July 20, 
2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you do not feel you should 
have to pay the copayment because the doctor scheduled the follow-up and not you. The Plan denied your 
request. The Plan says the copayment 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 $30 
copayment for provider and professional services in a specialist's office setting.  
 
You have been asked to pay a $30 copayment for a specialist office visit. A specialist office visit falls within 
the Physician/Practitioner Services, Including Doctor's Office Visits, benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a specialist office visit provided on July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit on January 20, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you should not be 
responsible for the copay because you did not receive any services at this appointment. The Plan denied your 
request. The Plan says the cost-sharing amount 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 $15 
copayment for visits to your specialists. Covered services include: Medically-necessary medical care or surgery 
services furnished in a physicians office, certified ambulatory surgical center, hospital outpatient department, 
or any other location. 
 
You have been asked to pay a $15 copayment for specialist office visit. Specialist office visit falls within the 
Physician/Practitioner services, including doctor's office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for specialist office visit on January 20, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ER visit provided on January 27, 2022. 
 
You asked the Plan to waive the copayment for ER visit. You say that this charge should be covered. The Plan 
denied your request. The Plan says the copayment applied 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 $110 
copayment for each covered emergency room visit.  
 
You have been asked to pay $110 copayment for ER visit. ER visits fall within the Emergency 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 ER visit provided on January 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dilantin. 
 
You asked the Plan to pre-approve Dilantin. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dilantin.  
 
Benefits for Dilantin may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI provided on March 11, 2022. 
 
You asked the Plan to waive the copayment for an MRI. You say that the MRI was necessary, and the amount 
of money is significant on your income. The Plan denied your request. The Plan says the copayment 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 $250 
copayment for all other diagnostic and nuclear medicine radiological services.  
 
You have been asked to pay a $250 copayment for an MRI. An MRI 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 MRI provided on March 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cyclosporine. 
 
You asked the Plan to pre-approve Cyclosporine. You say that every Cyclosporine or prescription dry eye 
medication is not covered by the insurance and the enrollee is in need of a healthy ocular surface. The Plan 
denied your request. The Plan says Cyclosporine is a self-administered drug and does not fall under Part B 
coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Cyclosporine.  
 
Benefits for Cyclosporine may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro 2 Motion G orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the enrollee has been referred by his family 
practice physician for myoelectric orthotic restoration, using the MyoPro Motion G. The Plan denied your 
request. The Plan says the requested myoelectric controlled upper limb orthosis is considered investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro 2 Motion G orthotic device (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you need this shower chair due to being 
overweight and with recent leg surgery you are not able to stand up. The Plan denied your request. The Plan 
says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on January 6, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the laboratory testing. You say that the laboratory test was ordered by an in-
network provider. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
laboratory testing. We found no exception that would require the Plan to pay for the laboratory testing. The 
record shows the referring provider was out-of-network. Therefore, we decided that the Plan does not have to 
pay for laboratory testing provided on January 6, 2022, 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 the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that it was not your choice to 
be transported between hospitals for treatment. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment for each ambulance trip. You had two (2) ambulance trips. The Plan charged you $450 for these 
services. 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for technetium and adenosine injections 
provided on October 19, 2021. 
 
You asked the Plan to waive the coinsurance for the injections. You say that you thought the procedure would 
be covered in full. 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 each Part B drug. 
 
Drug Allowed Amount 20% Coinsurance 
Technetium $708.00 $141.60 
Adenosine $0.60 $0.12 
Total:  $141.72 
 
 You have been asked to pay $141.72, which is 20% of the allowed amount for the injections. The 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 technetium and adenosine injections provided on October 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on January 20, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that it was medically necessary to treat the 
enrollee and you would like the claim to be paid. The Plan denied your request. The Plan says the rendering 
provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the physician services provided on January 20, 
2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the stereotactic computer-assisted (navigational) procedure 
(61783-AS) as billed with the assistant at surgery modifier 
 
You asked the Plan to pay for the stereotactic computer-assisted (navigational) procedure as billed with a 
surgery assistant. You say that you would like this claim reprocessed as the medical records show the assistant 
at surgery was medically necessary. The Plan denied your request. The Plan says the assistant at surgery was 
not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary 
are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment 
restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to 
establish medical necessity. In this case, you billed assistant surgery services for Current Procedural 
Terminology (CPT) code 61783. The Medicare Fee Schedule Database contains a surgical indicator of 0 for 
this procedure.  
 
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 stereotactic computer-assisted 
(navigational) procedure as billed with a surgery assistant. Our reviewer says that the assistant at surgery was 
not medically necessary based on the medical records. Our physician reviewer found that the enrollee is a 71-
year-old woman with lumbar spinal stenosis, lumbar radiculopathy, and spondylosis of the lumber spine. 
Fusion at L3-L4 and L4-L5, and percutaneous pedicle screws L3 to L5 were performed with utilization of 
somatosensory evoked potentials, and allograft bone. An assistant was used to provide retraction, visualization 
of neurovascular structures, along with exposure and closure of incisions. In this case, the operating note does 
not sufficiently support that an assistant at surgery was medically reasonable and necessary for the billed 
procedure. 
 
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 stereotactic computer-assisted (navigational) procedure as billed with a 
surgery assistant have not been met. Therefore, we decided that the Plan does not have to pay for the 
stereotactic computer-assisted (navigational) procedure (61783-AS) as billed with the assistant at surgery 
modifier
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for ambulance transportation provided on 
October 5, 2021. 
 
You asked the Plan to reduce the copayment for the ambulance transportation. You say that your broker 
informed you that the ambulance charge should only be $225. 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 $250 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $250 copayment for the ambulance transportation. The ambulance transportation 
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 reduce the copayment for 
ambulance transportation provided on October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on January 27, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that since this was part of your physical it 
should be covered. The Plan denied your request. The Plan says the copayment applied 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 $10 
copayment for additional services addressed during your annual wellness visit.  
 
 You have been asked to pay $10 copayment for the office visit. Office visit falls within the 
Physician/Practitioner services, including doctors 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 office visit provided on January 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Azacitidine. 
 
You asked the Plan to pre-approve Azacitidine. The Plan denied your request. The Plan says the requested drug 
would be deemed a routine cost covered by the Medicare Administrative Contractor (MAC). 
 The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Azacitidine as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve Azacitidine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an oxygen concentrator provided on 
December 9, 2021. 
 
You asked the Plan to waive the coinsurance for an oxygen concentrator. You say that you met your maximum 
out-of-pocket and the charges should be covered 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 in-network Medicare-covered Durable Medical Equipment (DME). Your contract with the Plan 
clearly says your in-network maximum out-of-pocket (MOOP) amount is $4,900. At the time this claim was 
submitted, you had paid $4891.42 towards your $4,900 in-network MOOP.  You have been asked to pay $8.58 for an oxygen concentrator ($4,900 - $4891.42 = $8.58 left towards MOOP). 
An oxygen concentrator 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 an oxygen concentrator provided on December 
9, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on January 25, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you don't think you were charged 
this much last time you received this service. The Plan denied your request. The Plan says the copayment 
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 $100 
copayment for a Medicare-covered ultrasound.  
 
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 provided on January 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital inpatient care service provided on January 13, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for initial hospital inpatient care service. You say that you are asking for 
reconsideration of the claim. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
initial hospital inpatient care service. We found no exception that would require the Plan to pay for the initial 
hospital inpatient care service. Therefore, we decided that the Plan does not have to pay for initial hospital 
inpatient care service provided on January 13, 2022, by an out-of-network (OON) provider.