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

 
We decided that the Plan does not have to waive your $90 copayment for emergency care provided by Niagara 
Falls Memorial Medical Center on February 2, 2022. 
 
You asked the Plan to waive your $90 copayment emergency services. You say that you are disputing the $90 
copayment for an ER visit because you were never at this medical center and should not be billed for it. The 
Plan denied your request. The Plan says you must pay a $90 copayment per Emergency room visit within or 
outside the service area. 
 
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 Emergency Care.  
 
You have been asked to pay a $90 copayment for emergency services. emergency services 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 your $90 copayment for emergency 
care provided by Niagara Falls Memorial Medical Center on February 2, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on December 
12, 2021. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you had no say in what kind 
of transportation you used, and this should only be a $40 copayment since you only needed a ride to the skilled 
nursing facility. 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 $325 
copayment per trip for Medicare-covered ambulance services Ambulance services. 
 
 You have been asked to pay $325 copayment for ambulance transport. Ambulance transport falls within the 
Ambulance services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. 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 ambulance transport 
provided on December 12, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the out of network mental health care visit 
provided on December 9, 2021. 
 
You asked the Plan to waive the copayment for out of network mental health care visit. You say that you were 
told the provider was in network so you shouldn't be charged for out of network. 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 $60 
copayment for each out of network Medicare covered individual or group therapy visit. 
 
 
 
 You have been asked to pay $60 copayment for the out of network mental health care visit. Mental health care 
visits fall within the Outpatient mental health 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 out of network mental health care visit provided on December 9, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing admission provided from 
November 1, 2021, to November 18, 2021. 
 
You asked the Plan to waive the copayment for skilled nursing admission. You say that this charge should be 
covered since you didn't receive any therapy while you were there. 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 $75 
copayment per day for days 21 through 87 at a SNF.  
 
 
 
  
You have been asked to pay $1,125.00 total for your SNF services ($75/day x15 days = $1125). Skilled nursing 
admission falls within the Skilled nursing facility (SNF) 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 skilled nursing admission provided from November 1, 2021, to November 18, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insertion of permanent cardiac contractility 
modulation system with pulse generator with transvenous electrodes (placement of a heart device). 
 
You asked the Plan to pre-approve an insertion of permanent cardiac contractility modulation system. You say 
that the requested procedure is medically necessary. The Plan denied your request. The Plan says the requested 
procedure does not meet criteria. 
 
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 pre-approve an insertion of permanent cardiac 
contractility modulation system. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found while the clinical studies led to 
FDA approval in 2019, CCM remains the subject of multiple studies examining long-term efficacy, as well as 
randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous 
studies are completed, it is premature to presume clinical outcomes and benefit. 
 
 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 insertion of permanent cardiac contractility modulation system have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an insertion of permanent cardiac 
contractility modulation system with pulse generator with transvenous electrodes (placement of a heart device).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Office visit on January 31, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that this was not your annual routine visit 
and do not want this visit to be considered your annual visit. The Plan denied your request. The Plan says the 
cost-sharing amount the enrollee is 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 $5 
copayment per visit for primary care provider (PCP) and $35 copayment per visit for a Specialist. $0 
copayment per visit in a certified ambulatory surgical center or hospital outpatient department.  
 
You have been asked to pay a $5 copayment for 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 on January 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit and hearing exam provided 
on January 20, 2022. 
 
You asked the Plan to waive the copayment for an office visit and hearing exam. You say that the hearing exam 
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 $35 
copayment for a specialist office visit and a $5 copayment for diagnostic lab services and diagnostic 
procedures. 
 
 You have been asked to pay a $35 copayment for the office visit and a $5 copayment for the hearing exam. The 
total amount you owe is $40 ($35 + $5= $40). An office visit falls within the Physician/Practitioner services, 
including doctor's office visits benefit category. The hearing exam 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 office visit and hearing exam provided on January 20, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Daliresp. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 Daliresp.  
 
Benefits for these services 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
February 22, 2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that you only had a stitch removed. 
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 $45 
copayment for each visit with a specialist.  
 
 
 
 
 
 
 You have been asked to pay a $45 copayment for the office visit. The 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 February 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness for an upgrade to expandable controller 
(E2313) and an expandable controller (E2377). 
 
You asked the Plan to pre-approve power wheelchair accessories. You say that the requested items are 
necessary. The Plan denied your request. The Plan says there is not a medical need to control these power 
options through the joystick and these items do not service a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 
 
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller and 
two or more power seating system motors (E2311), a harness for an upgrade to expandable controller (E2313) 
and an expandable controller (E2377).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit and refraction provided on 
January 21, 2022. 
 
You asked the Plan to waive the copayment for the office visit and refraction. You say that this charge should 
be covered. The Plan denied your request. The Plan says the $20 copayment applied correctly, and the 
refraction remains denied. 
 
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 pay a $20 
copayment for Medicare covered vision services in a specialists office and a refraction is only covered when 
billed as part of the routine eye exam 
 
You have been asked to pay $20 copayment for the office visit. The office visit falls within the Vision care 
benefit category. In addition, the refraction remains denied as it was not provided with a routine eye exam and 
you are responsible for the full cost of this service. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for the office visit and refraction provided on January 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 8, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids provided on September 19, 2021, from an out-
of-network provider. 
 
You asked the Plan to pay for out-of-network hearing aids. You say that you were told you could be 
reimbursed $700 per ear, and you were not told that you had to use a network provider. The Plan denied your 
request. The Plan says you must purchase hearing aids through the Plan's specified routine hearing vendor in 
order for them to be covered by the Plan. The provider in this case is not part of the Plan's routine hearing 
network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are received through the Plan's specified hearing vendor.  
 
We looked at the file and the Plan's rules. The hearing aids in this case were purchased from a provider outside 
of the Plan's specified routine hearing vendor network. Based on this information, we decided that the Plan's 
rules for coverage of out-of-network hearing aids have not been met. Therefore, we decided that the Plan does 
not have to pay for hearing aids provided on September 19, 2021, from an out-of-network provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 
You asked the Plan to pre-approve Ilumya. You say that the requested Ilumya is medically necessary. The Plan 
denied your request. The Plan says the enrollee must try and fail Stelara first. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Ilumya. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of Stelara 
first before they will approve the requested drug. In this case, the enrollee has not tried and failed the required 
drug(s). There is no documentation indicating that the plans required drug(s) would likely be less effective 
and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that this enrollee requires SNF admission. The 
Plan denied your request. The Plan says the enrollee does not need daily skilled care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pre-approve the SNF admission. Our reviewer says 
that the requested SNF admission does not meet criteria. Our physician reviewer found the enrollee does not 
have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The 
enrollee is not shown to have an acute decline in function. Daily skilled services are not shown to be required 
to establish a maintenance program or to prevent deterioration of the enrollees condition. The enrollees care 
needs, as a practical matter, can be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive your $20.32 coinsurance for a knee brace provided on  
August 5, 2021. 
 
You asked the Plan to waive your $20.32 coinsurance for a knee brace. You say that you were told the brace 
would be covered and you would not have to pay anything. The Plan denied your request. The Plan says you 
must pay a 20% coinsurance for in-network Medicare-covered durable medical equipment and related supplies. 
 
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 Related Supplies.  
 
 
 
 You have been asked to pay a 20% coinsurance for a knee brace. A knee brace 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 your $20.32 
coinsurance for a knee brace provided on August 5, 2021.  
 
Your complaint about having been told you would not have to pay anything for the knee brace is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on December 
21, 2021. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that you only went for a COVID-
19 test. 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 $45 
copayment for urgent care services with providers other than your PCP.  
 
You have been asked to pay a $45 copayment for the urgent care visit. The urgent care visit falls within the 
Urgently Needed 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 an urgent care visit provided on 
December 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 24, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on February 24, 2021.