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

 
We decided that the Plan does not have to waive the copayment and coinsurance for an Injection, Podiatry 
service and X-Rays on September 20, 2021 
 You asked the Plan to waive the copayment and coinsurance for an Injection, Podiatry service and X-Ray. You 
say that the amount is incorrect. The Plan denied your request. The Plan says costsharing is a contractual 
obligation of the plan and cannot be waived. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for Podiatry service, 20% coinsurance for an Injection and $15 copayment for each X-Ray. The 
allowed amount of the injection is $5.16, resulting in a coinsurance amount of $1.03. There were 2 X-Rays, 
resulting in a copayment amount of $30. Therefore, your total cost-sharing amount is $66.03. 
 
You have been asked to pay a $35 copayment a Podiatry service, 20% coinsurance for an Injection and two $15 
copayments for two X-Rays. The Injection falls within the Medicare Part B Prescription Drugs benefit 
category. The Podiatry service falls within the Podiatry Services benefit category. The X-Ray 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 and coinsurance for an Injection, Podiatry service and X-Rays on September 20, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no complex care needs. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are no acute rehabilitation or nursing needs identified or documented in the 
records. You are medically stable and do not need physician supervision three times per week (at a minimum) 
for the ongoing management of any active or acute exacerbations of chronic medical conditions. At the current functional level, it is unlikely that you will make significant functional recovery in a predicted period of ten 
days in the IRF. You need a skilled nursing facility (SNF) level of care. You do not need intensive therapies, 
consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to 
daily therapy in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a podiatry visit and X-rays of the foot 
provided on November 12, 2021. We also decided that the Plan does not have to waive the coinsurance for a 
walking boot provided on November 12, 2021. 
 You asked the Plan to waive the copayments and coinsurance for the podiatry visit, X-rays, and walking boot. 
You say that you feel you should not be responsible for any copayments or coinsurance. The Plan denied your 
request. The Plan says the correct copayments and coinsurance were 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 $30 
copayment for each podiatry visit. 
 
Your contract with the Plan also clearly says that you must pay a $35 copayment for X-rays. 
 
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for durable medical 
equipment (DME), including walking boots. 
 
You have been asked to pay a $30 copayment for the podiatry visit. The podiatry visit falls within the Podiatry 
Services benefit category. You have also been asked to pay a $35 copayment for the X-rays. The X-rays fall 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. You have also 
been asked to pay $53.93 for the walking boot, which is 20% of the allowed amount ($269.63 allowed amount 
x 20% coinsurance = $53.93). The walking boot falls within the Durable Medical Equipment (DME) and 
Related Supplies benefit category. The total for your visit is $118.93. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayments for a podiatry visit and X-rays of the foot provided on November 12, 2021. We also decided that 
the Plan does not have to waive the coinsurance for a walking boot provided on November 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayment for the ophthalmological medical examination 
and evaluation (92014) provided on March 2, 2021. 
 
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $50 
copayment for Medicare-covered vision services.  
 
You have been asked to pay a $50 copayment for the Medicare-covered vision service provided. 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 adjust the copayment for the ophthalmological medical examination and 
evaluation (92014) provided on March 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation office visit and a cataract removal surgery 
provided on by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a consultation office visit and a cataract removal surgery. You say that you were 
informed by the Plan that this provider was in-network. You also say you were told by your doctor to not use 
the in-network provider for your surgery. The Plan denied your request. The Plan says your records received do 
not indicate that you have an emergent or urgent medical condition, or are in need of specialized services that 
are not available in the network. The Plan also says there are in-network provider(s) within a reasonable 
distance from your location that can provide this service. 
 
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 consultation office visit and a cataract removal 
surgery provided on by an out-of-network (OON) provider.  
 
Your complaint about potentially being misinformed about in-network providers 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy visits provided on 
November 19, 2021 through November 30, 2021. 
 
You asked the Plan to waive the copayment for physical therapy visits. You say that you were not informed 
there would be a copayment so it should be waived.  The Plan denied your request. The Plan says the 
copayment amount 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 $40 
copayment for physical therapy services provided in an outpatient hospital setting. 
 
 You have been asked to pay $160 for four physical therapy visits ($40x4). Physical therapy visits fall within 
the Outpatient Rehabilitation 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 
physical therapy visits provided on November 19, 2021 through November 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99213) provided on  
July 14, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $25 
copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse 
practitioner or physicians assistant or other non-physician health care professionals in a specialists office. You have been asked to pay a $25 copayment for the specialist visit provided. 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 office visit (99213) provided on July 14, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy services provided on 
December 2, 2021 
 
You asked the Plan to waive the copayment for physical therapy services. You say that the copayment should 
be waived because the service was not necessary. The Plan denied your request. The Plan says the copayment 
amount 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 $25 
copayment for physical therapy provided at a specialist's office, outpatient hospital, or comprehensive 
outpatient rehab facility.  
 
 
 
 
 You have been asked to pay a $25 copayment for physical therapy services. Physical therapy services fall 
within the Outpatient Rehabilitation 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 physical therapy services provided on December 2, 2021. 
 
Please note that this decision is only regarding your appeal for physical therapy services provided on December 
2, 2021. Please contact the Plan regarding appeals for any other items or services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an echocardiography (93306) provided on 
November 5, 2021. 
 
You asked the Plan to waive the copayment for the echocardiography. You say that the services should be 
covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 
provided. 
 
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 $50 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $50 copayment for an echocardiography. Echocardiographys 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 an echocardiography (93306) provided on November 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a patient lift with a seat sling or pad to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a patient lift with a seat sling or pad. You say that you would like the Plan 
to make a rural exception in the patient's favor, and that the physical therapist wrote on the form that the patient 
requested to use your company due to other companies being over 40 miles from her home. The Plan denied 
your request. The Plan says this provider is an out-of-network provider. The Plan also says that there are in-
network providers available. 
 
 
 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 patient lift with a seat sling or pad to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve alprazolam. 
 
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 alprazolam.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an X-Ray on November 17, 2021 
 
You asked the Plan to waive the copayment X-Ray. You say that you were told to get x-rays for an outpatient 
procedure The Plan denied your request. The Plan says the copayment you are being charged is correct as the 
medically necessary services provided were in the outpatient department of a hospital 
 
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 $150 
copayment for an in-network X-Ray at an outpatient hospital facility.  
 
You have been asked to pay $150 copayment for X-Ray. An X-Ray falls within the in-network 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 X-Ray on November 17, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for bortezomib injections (J9041) provided 
from April 5, 2021, to April 26, 2021. 
 
You asked the Plan to waive the coinsurance for the bortezomib injections. You say that the services should be 
covered as you were not aware of the costs beforehand and cannot afford to pay. The Plan denied your request. 
The Plan says the coinsurance applied correctly based on the services provided. 
 
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 Medicare Part B prescription drugs.  
 
 
  You have been asked to pay a 20% coinsurance for six bortezomib injections (the total allowed is $4,732.50 x 
20% = $945.5). Bortezomib 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 bortezomib injections (J9041) provided from April 5, 2021, 
to April 26, 2021.
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 October 
24, 2021. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that the COVID-19 test was lost 
and you did not get results. 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 $15 
copayment for each urgent care visit.  
 
You have been asked to pay a $15 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 October 24, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have the copayment for the ambulance transport provided on August 15, 
2021. 
 
You asked the Plan the copayment for the ambulance transport. You say that the ambulance was required, as 
you were hallucinating and dehydrated. 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 
copay for each Medicare-covered one-way trip via ground ambulance.  
 
You have been asked to pay $295 copay for the ambulance transport. The 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.  
 
Medicare rules say that mileage is only covered to the nearest appropriate facility equipped to treat the patient 
is covered. You can find this rule in Medicare Benefit Policy Manual Chapter 10, Section 10.3. 
 
You have been asked to pay for the non-covered mileage. Because you chose not to be transported to the 
nearest facility, the mileage was not covered by Medicare. There is a $15 charge per mile, and the trip was 15 
miles, making the total for this portion of the charges $225. The copay for the covered transport plus the non-
covered mileage is $520 ($295+$225). Therefore, we decided that the Plan does not have the copayment for the 
ambulance transport provided on August 15, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy (90832) and a psychiatric diagnostic 
evaluation (90791) provided from June 10, 2021, to June 29, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy and a psychiatric diagnostic evaluation. You say that you are 
appealing with supporting records. The Plan denied your request. The Plan says this provider is not a network 
provider with the Plan and there is not a referring provider. 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 psychotherapy (90832) and a psychiatric 
diagnostic evaluation (90791) provided from June 10, 2021, to June 29, 2021, by an out-of-network (OON) 
provider.