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

 
We decided that the Plan does not have to waive the copayment for EKG provided on April 8, 2022. 
 
You asked the Plan to waive the copayment for EKG. You say that since this was part of your pre-op 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 $100 
copayment for diagnostic procedures and tests performed in an outpatient hospital. 
 
You have been asked to pay $100 copayment for EKG. EKG 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 
EKG provided on April 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient rehabilitation care provided from 
August 24, 2021, to September 4, 2021. 
 
You asked the Plan to waive the copayment for the inpatient rehab. You say that you recovered at a different 
facility after surgery and this should be part of that stay. 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 $300 per 
day for days 1-6 and $0 per day for additional days for each admission, including transfers.  
 
The file shows that you were in the rehab facility from August 24, 2021, to September 4, 2021. Therefore, you 
have been asked to pay $300 per day for the first 6 days of inpatient rehab. The total for your stay is $1,800 
($300 copayment x 6 days = $1,800). The inpatient rehab falls within the Inpatient Hospital Care benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for inpatient rehabilitation care provided from 
August 24, 2021, to September 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Outpatient visit on January 20, 2022, to 
January 28, 2022. 
 
You asked the Plan to waive the copayment for outpatient visit. You say that why would the plan put out a 
spreadsheet saying you would have to pay nothing and then charge you $10 of each visit. 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 $10 
copayment for all other Medicare-covered outpatient hospital services. We cover medically-necessary services 
you get in the outpatient department of a hospital for diagnosis or treatment of an illness or injury. Covered 
services include, but are not limited to: Services in an emergency department or outpatient clinic, such as 
observation services or outpatient surgery. Laboratory and diagnostic tests billed by the hospital. There were 3 
visits, resulting in a total copayment amount of $30.  
 
 You have been asked to pay a $10 copayment for outpatient visit. Outpatient visit 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 copayment for Outpatient visit on 
January 20, 2022, to January 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on January 27, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that it is the facilities responsibility to obtain the 
authorization needed and the service rendered was out of medical necessity. 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 a home health visit provided on January 27, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for surgical procedure of the spine provided on 
December 1, 2021. 
 
You asked the Plan to waive the copayment for surgical procedure of the spine. You say that you are on a fixed 
income and cannot afford this payment so it should be waived. 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 $275 
copayment for each Medicare-covered outpatient surgery at a hospital outpatient facility.  
 
 
 
 
 You have been asked to pay $275 copayment for surgical procedure of the spine. Surgical procedures 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 surgical procedure of the 
spine provided on December 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for  ECG provided on February 9, 2022. 
 
You asked the Plan to waive the copayment for ECG. You say that you feel this should be covered since your 
doctor recommended it. 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 $20 
copayment for Medicare covered non-radiological diagnostic services.  
 
You have been asked to pay $13.84 which is less than the standard $20 copayment for ECG. ECGs fall 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  ECG provided on February 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for debridement, provided on January 31, 
2022. 
 
You asked the Plan to waive the copayment for debridement.. You say that this was done at a normal facility so 
should only be charged $35 copayment. 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 $295 
copayment for Medicare covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges.  
 
 
 
 You have been asked to pay $295 copayment for debridement. Debridement falls within the Outpatient Surgery 
and Other Medical 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 debridement, provided on January 31, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a transthoracic echocardiogram (TTE) with 
doppler provided on January 14, 2022. 
 
You asked the Plan to waive the copayment for the TTE with doppler. 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 $90 
copayment for diagnostic procedures and tests at an outpatient hospital.  
 
You have been asked to pay a $90 copayment for the TTE with doppler. The TTE with doppler 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 transthoracic echocardiogram (TTE) with doppler provided on January 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for aflibercept and bevacizumab injections 
provided on February 9, 2022. 
 
You asked the Plan to waive the coinsurance for the injections. You say that you are paying too much for the 
injections. 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 
Aflibercept $1,831.50 $366.30 
Bevacizumab $67.86 $13.57 
Total:  $379.87 
  
You have been asked to pay $379.87, 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 aflibercept and bevacizumab injections provided on February 9, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Botox. 
 
You asked the Plan to pre-approve the Botox. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 the Botox. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found Dysphagia, nausea and gastroesophageal 
reflux disease with esophagogastric junction outflow obstruction are not medically-accepted indications for 
Botox. 
 
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 Botox have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Botox.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on 
January 4, 2022. 
 
You asked the Plan to waive the copayment for the telehealth visit. You say that you only spoke to the doctor 
for 20 minutes and 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 $30 
copayment for specialist visits, including telehealth.  
 
You have been asked to pay a $30 copayment for the telehealth visit. The telehealth visit falls within the 
Doctor 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 telehealth visit 
provided on January 4, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
March 23, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. You say that the doctor was not able to help you 
and you were sent to the burn unit. 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 $90 
copayment for each emergency care visit.  
 
The file shows that you were triaged and evaluated by the ER staff. Therefore, you have been asked to pay a 
$90 copayment for the ER visit. The ER visit falls 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 an emergency room (ER) visit provided on March 23, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for aflibercept injections provided from 
October 11, 2021, to February 14, 2022. 
 
You asked the Plan to reduce the coinsurance for the injections. You say that you should not have to pay more 
than $20 per visit. 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 
Aflibercept  October 11, 2021 $1,835.90 $367.18 
Aflibercept  December 13, 2021 $1,835.90 $367.18 
Aflibercept  February 14, 2022 $1,831.50 $366.30 
Total:  $1,100.66 
 
You have been asked to pay $1,100.66, 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 reduce the 
coinsurance for aflibercept injections provided from October 11, 2021, to February 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for wound care equipment provided from 
January 7, 2021, to November 4, 2021. 
 
You asked the Plan to waive the coinsurance for the wound care equipment. You say that you were informed 
the equipment would be provided at no cost. 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 durable medical equipment (DME) item, including wound care equipment. 
 
 
 
 
 Item Allowed Amount 20% Coinsurance 
Wound Care Set  January 7, 2021 $384.00 $76.80 
Wound Pump  January 7, 2021 $1,601.80 $320.36 
Disposable Canister  January 7, 2021 $89.00 $17.80 
Wound Care Set  January 18, 2021 $384.00 $76.80 
Disposable Canister  January 18, 2021 $89.00 $17.80 
Wound Pump  February 7, 2021 $1,601.80 $320.36 
Wound Care Set  March 5, 2021 $384.00 $76.80 
Disposable Canister  March 5, 2021 $89.00 $17.80 
Wound Care Set  March 6, 2021 $128.00 $25.60 
Disposable Canister  March 6, 2021 $44.50 $8.90 
Wound Pump  April 20, 2021 $1,601.80 $320.36 
Wound Care Set  April 23, 2021 $384.00 $76.80 
Wound Pump  June 4, 2021 $1,601.80 $320.36 
Wound Care Set  June 24, 2021 $384.00 $76.80 
Disposable Canister  June 24, 2021 $89.00 $17.80 
Wound Pump  July 4, 2021 $1,601.80 $320.36 
Wound Pump  August 4, 2021 $1,601.80 $320.36 
Wound Pump  September 4, 2021 $1,601.80 $49.00 (MOOP) met 
Wound Pump  October 4, 2021 $1,601.80 $0.00 
Wound Pump  November 4, 2021 $1,601.80 $0.00 
Total:  $2,460.86 
 
You have been asked to pay $2,460.86, which is 20% of the allowed amount for the wound care equipment. 
Please note that on the claim for September 4, 2021, you met your maximum out-of-pocket (MOOP) expenses 
for the year, resulting in a reduced coinsurance. There are also no charges after this date. The wound care 
equipment 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 wound care equipment provided from January 7, 2021, to 
November 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0823) and accessories (E2365. 
E1028, K0108) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the enrollee needs these 
items. The Plan denied your request. The Plan says these items are available in-network. 
 
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 (K0823) and accessories (E2365. E1028, K0108) to be provided 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 portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the requested device is to be used for the 
treatment of COPD. The Plan denied your request. The Plan says the requested device does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you have severe COPD requiring 
supplemental oxygen. Medicare criteria for nocturnal ventilatory support are not met because there is no 
documentation of chronic O2 retention with an ABG done as an outpatient while stable. If you do have CO2 
retention, the AVAPS mode can be provided via bipap. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that the doctor who saved your life 20 years ago 
referred you to this out-of-network provider. You say the surgery you will need is medically necessary. 
 The Plan denied your request. The Plan says the provider is out-of-network. 
 
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 office visit in this appeal. We found no exception that would require the Plan to 
pre-approve the office visit. The records provided for review do not show that the service at issue is urgent or 
emergent. Therefore, we decided that the Plan does not have to pre-approve the office visit to be provided by 
an out-of-network (OON) provider.