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

 
We decided that the Plan does not have to waive the coinsurance for a Duralane (hyaluronan) injection 
provided on October 14, 2021. 
 
You asked the Plan to waive the coinsurance for an injection. You say that no one informed you that you would 
have an out-of-pocket expense for this service. You also say that you should have been informed prior to 
receiving the service. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Part B drugs.  
 
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
$206.76, which is 20% coinsurance of the allowed amount for an injection ($1,033.80 allowed amount x 20% 
coinsurance = $206.76). An injection 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 a Duralane (hyaluronan) injection provided on October 14, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthotic device. 
 
You asked the Plan to pre-approve the requested device. You say that this treatment can deliver more intensive 
practice. The Plan denied your request. The Plan says experimental procedures are not covered by Medicare. 
 
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 the requested device. Our physician 
reviewer found that the device is being requested for the treatment of the patient's left upper extremity partial 
paralysis due to a cerebral infarction in November of 2016. The enrollee has engaged in physical and 
occupational therapy, static bracing, electric stimulation, and Botox injections for the management of her 
partial paralysis. She remains with functional limitations in activities of daily living. The MyoPro is not known 
to be effective, based on scientific evidence, professional standards and expert opinion, in improving health 
outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is 
insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this 
enrollee, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the 
literature that this device will increase participation in bimanual activities. 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 requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a MyoPro orthotic device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a triamcinolone acetonide injection, and an arthrocentesis, 
aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound 
guidance  provided on January 19, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a triamcinolone acetonide injection, and an arthrocentesis, aspiration and/or 
injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance. You 
say that this provider regularly complies with all administrative requirements for payments. The Plan denied 
your request. The Plan says there is not a referral on file, and the primary care physician's office stated they did 
not refer the member to the rendering provider. The Plan also says that this provider is not a network provider with the Plan, and they have also determined that these services are not urgent or emergent, nor were they 
approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a triamcinolone acetonide injection, and an 
arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); 
without ultrasound guidance  provided on January 19, 2022, 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 therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this is medically reasonable and necessary. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
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 a therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic continuous glucose monitor (CGM).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the imaging and the coinsurance for the 
injection.  
 
You asked the Plan to waive the copayment for the imaging and to waive the coinsurance for the injection. You 
say that you were told all services would be covered. The Plan denied your request. The Plan says the 
copayment and coinsurance applied 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 $275 
copayment for the imaging and 20% coinsurance for the injection.  
 
You have been asked to pay a total of $322.76 for the imaging and the injection.  
 
Service Allowed Amount Copayment/Coinsurance Member Liability 
Myocardial Perfusion 
Imaging  
$487.52 $275 copayment $275 
Regadenoson Injection $238.80 20% coinsurance $47.76 
TOTAL:   $322.76 
 
Myocardial perfusion imaging falls within the Outpatient diagnostic tests and therapeutic services and 
supplies benefit category. The regadenoson injection 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 copayment for the myocardial perfusion 
imaging and the coinsurance for the regadenoson injection provided on December 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on November 19, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the assisted living facility is 
responsible to obtain prior authorization for all of their patients, which should also cover for the medical 
treatments provided by this provider. The Plan denied your request. The Plan says this provider is not a 
network provider with the Plan, and the services were not referred by a network provider or rendered in an in-
network facility. The Plan also says that they have also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a domiciliary or rest home visit provided on 
November 19, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Pathology services provided on October 20, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Pathology services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says prior authorization is required for an out-of-network 
visit and it was determined these services can be received 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 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 Pathology services provided on October 20, 2021 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on November 15, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that this provider is in-network with the Plan. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advance. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit provided on November 15, 2021 by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the durable medical equipment (DME) 
supplies provided on January 19, 2022. 
 
You asked the Plan to waive the coinsurance for the DME supplies. You say that you have never paid for the 
supplies in previous years and would like the coinsurance waived. The Plan denied your request. The Plan says 
the proper 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 Medicare-covered durable medical equipment item. The total amount allowed for the 
DME supplies was $8.75 with a coinsurance of $1.75 ($8.75 total amount x 20% coinsurance). 
 You have been asked to pay a $1.75 coinsurance for the DME supplies. The DME supplies 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 the durable medical equipment (DME) supplies provided on January 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for inpatient hospital care provided from 
October 3, 2021, to October 8,2021, and from October 8, 2021, to October 26, 2021. 
 
You asked the Plan to reduce the copayments for inpatient hospital care. You say that you should only have to 
pay the first five days that your father was in the hospital. You also say he was transferred to another facility 
for continuing care and should not have to pay the cost share for two facilities. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $175 copayment per day for days 1-5 for inpatient hospital care.  
 
 The record shows these claims were approved, and there is a cost sharing amount for each facility. The enrollee 
has been asked to pay a total of $700, which is a $175 copayment per day for days 1-4 of inpatient hospital care 
from October 3, 2021, to October 8, 2021 ($175 copayment x 4 days = $700).  There is no charge for the day of 
discharge. The enrollee has also been asked to pay a total of $800, which is a $175 copayment per day for days 
1-5 of inpatient hospital care from October 8, 2021, to October 26, 2021 ($175 copayment x 5 days = $800). 
Inpatient hospital care falls within the Inpatient Hospital Care benefit category. This means that the enrollee 
has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to reduce the copayments for inpatient hospital care provided from October 3, 2021, to October 8,2021, 
and from October 8, 2021, to October 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on November 1, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that this provider was not responsible to 
obtain authorization, and the assisted living facility is responsible to obtain prior authorization for all of their 
patients. The Plan denied your request. The Plan says this provider is out-of-network with the Plan, and 
authorization was not obtained prior to the services being rendered. 
 
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 domiciliary or rest home visit provided on 
November 1, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided by a network 
facility from September 18, 2020, to September 23, 2020. 
 
You asked the Plan to waive the copayment for the outpatient surgery. You say that you are appealing this 
claim. The Plan denied your request. The Plan says you have been asked to pay 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 $350 
copayment for each visit to an outpatient hospital facility.  
 
 You have been asked to pay a $350 copayment for the outpatient surgery. The outpatient surgery 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 surgery provided by a network facility from September 18, 2020, to September 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) supplies provided on 
January 21, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the DME supplies. You say that the supplies were delivered to your residence 
and would like the claim reprocessed for payment. The Plan denied your request. The Plan says the rendering 
provider is an out-of-network provider and there was no referral from the enrollee's primary care physician to 
use an out-of-network provider. Also, the services were 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 durable medical equipment (DME) supplies 
provided on January 21, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the echocardiography provided on June 17, 
2021, 
 
  You asked the Plan to waive the copayment for the echocardiography. You say that you would like this service 
to be covered. The Plan denied your request. The Plan says the copayment applied 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 an $85 
copayment for Medicare-covered radiological diagnostic services. 
 
You have been asked to pay an $85 copayment for the echocardiography. The echocardiography falls within 
the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the echocardiography provided on June 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for inpatient hospital care provided from 
November 18, 2021, to November 25, 2021. 
 
You asked the Plan to waive the coinsurance for the inpatient care. You say that the charges appear to be for 
transport service, and there was no ambulance or paramedics involved. 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 40% 
coinsurance for each inpatient stay at an out-of-network (OON) facility.  
 
The file shows that the Plan has verified the provider is not a network provider. The Plan has also verified that 
the charges are for the inpatient care entirely, and not just the transport portion. Therefore, you have been asked to pay $6,189.14, which is 40% of the allowed amount for the OON inpatient care ($15,472.85 allowed amount 
x 40% coinsurance = $6,189.14). The inpatient care 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 coinsurance for inpatient hospital care provided from November 18, 2021, 
to November 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for An office visit provided on December 13, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for An office visit. You say that you would like to appeal the denial of the claim. 
The Plan denied your request. The Plan says prior authorization is required for an out-of-network visit. 
 
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 An office visit provided on December 13, 2021 by 
an out-of-network (OON) provider.