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

 
We decided that the Plan does not have to waive the coinsurance for a denosumab injection provided on June 
22, 2022. 
 
You asked the Plan to waive the coinsurance for a denosumab injection. You say that you have never received 
a bill for these injections before, and you have been getting them for years. The Plan denied your request. The 
Plan says this cost sharing was charged 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 20% 
coinsurance for Medicare Part B prescription drugs. The allowed amount of this drug or item is $1,275.60, 
resulting in a coinsurance amount of $255.12 ($1,275.60 x 20% = $255.12). 
 
You have been asked to pay a $255.12 coinsurance for a denosumab injection. This item/service 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 denosumab injection provided on June 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services on November 
19, 2021, to November 24, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital services. You say that you would like to 
appeal the cost share. The Plan denied your request. The Plan says this cost sharing was charged 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 10% 
coinsurance for inpatient hospital services. The cost-share is calculated by taking the Medicare-allowed amount 
and multiplying the coinsurance percentage. In this case, $9,680.84 x 10% = $968.08. The member would have 
had a cost share of $968.08, however, since the member was close to hitting their out-of-pocket maximum the 
member was only assessed the amount that was needed to finish off the member out-of-pocket maximum 
amount. Therefore, the member was assessed a lesser amount in the amount of $675.81. 
 
You have been asked to pay a 10% coinsurance for inpatient hospital services. This item/service 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 
hospital services on November 19, 2021, to November 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that additional therapy is medically necessary. The 
Plan denied your request. The Plan says the requested therapy is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 
 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 therapy visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that continued strength training is not a skilled service. The enrollee 
can maintain or improve her range of motion and her strength with repetitive exercise. Continued input from a 
skilled therapist is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve eight physical therapy visits.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve continuing services. The Plan denied your request. The Plan says your needs 
may be provided at a lower level of 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 continuing services. Our physician 
reviewer found that you no longer qualify for SNF coverage. You do not have documented skilled nursing or 
therapy needs. You are functioning at a minimal to supervision assist level. Daily skilled services are not 
required to establish a maintenance program or to prevent deterioration of your condition. Therefore, the 
request is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuing services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound on July 11, 2022. 
 
You asked the Plan to waive the copayment for ultrasound. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged 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 $125 
copayment for advanced imaging services at primary care providers (PCP) office, specialists office, and 
outpatient hospital. Covered services include, but are not limited to other outpatient diagnostic tests.  
 
You have been asked to pay a $125 copayment for ultrasound. This item/service 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 ultrasound on July 11, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy visits performed at an 
outpatient hospital provided from March 8, 2022, to June 30, 2022. 
 
You asked the Plan to waive the copayment for physical therapy visits. You say that you were unaware that a 
huge copayment balance was building up and were not informed. You say that you thought the visits were 
being covered by the Plan and are requesting the copayments be waived. The Plan denied your request. The 
Plan says this cost sharing was charged 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 $40 
copayment for physical therapy performed at an outpatient hospital facility.  
 
 
  You have been asked to pay a total of $960 for physical therapy visits ($40 per visit x 24 visits = $960). This 
item/service falls 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 performed at an outpatient hospital provided from March 8, 
2022, to June 30, 2022.  
 
Your complaint about not being informed of the physical therapy copayments 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hip orthosis (HO), abduction control of hip joint, 
postoperative hip abduction type, prefabricated, includes fitting and adjustment (L1686) and addition to lower 
extremity, pelvic control, hip joint, adjustable flexion, extension, abduction control, each (L2624) provided 
July 7, 2022. 
 
You asked the Plan to pay for the orthosis. You say that you have attached all the supporting documentation. 
Please reprocess the claim. The Plan denied your request. The Plan says this request is not medically necessary 
because the records do not show an appropriate face-to-face encounter documented in the records to 
substantiate the need for these items. 
 
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 pay for the orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case the record indicates that the enrollee has osteoarthritis of the hip. The record 
provided does not document the noted diagnosis or that the requested service was ordered. The record is 
insufficient to establish the medical necessity of the requested service. The record provided does not establish 
the medical necessity and reasonableness, as defined by Medicare rules of the requested service. The elements 
of the coverage criteria are not satisfied. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for the hip orthosis (HO), abduction control of hip joint, postoperative hip abduction type, 
prefabricated, includes fitting and adjustment (L1686) and addition to lower extremity, pelvic control, hip joint, 
adjustable flexion, extension, abduction control, each (L2624) provided July 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral appliance for sleep apnea (E0486). 
 
You asked the Plan to pre-approve an oral appliance for sleep apnea. You say that you disagree with the denial. 
The Plan denied your request. The Plan says Medicare criteria is not met, and medical necessity is not 
established as you have not had an evaluation and ordering of the oral appliance by a sleep specialist. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and medical necessity has been met.  
 
The record does not contain a valid physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. The record shows that you have not been evaluated by a sleep 
specialist, completed a sleep study and/or do not have an order for the oral appliance from your provider as 
needed. The device has not been ordered by the treating practitioner following a review of a sleep test. 
Therefore, we decided that the Plan does not have to pre-approve an oral appliance for sleep apnea (E0486).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the self-administered drugs (A9270) 
provided from October 24, 2021, through October 29, 2021. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these items are not covered under the 
enrollees contractual policy or by Medicare. 
 
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 provided are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to issue reimbursement for the self-
administered drugs (A9270) provided from October 24, 2021, through October 29, 2021.   
Benefits for these items 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 pay for an office visit (99212) and urinalysis (81003) provided on 
May 19, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for office visit services. You say that the services should be covered. The Plan 
denied your request. The Plan says the claim was processed correctly. The Plan says there was no referral on 
file for the services at issue. Additionally, the Plan found no evidence to support the services were urgent or 
emergent in nature. Since there was no prior authorization for the services, the claim remains denied. 
 
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 (99212) and urinalysis (81003) 
provided on May 19, 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 an x-ray on July 8, 2022. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you would like to appeal the cost share. 
The Plan denied your request. The Plan says this cost sharing was charged 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 $45 
copayment for an x-ray.  
 
You have been asked to pay a $45 copayment for an x-ray. This item/service 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 x-ray on July 8, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on July 07, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you are on a fixed income and the 
copayment would cause a financial hardship. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $100 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $100 copayment for an ultrasound. This item/service falls within the outpatient 
diagnostic test benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan.  Therefore, we decided that the Plan does not have to waive the copayment for an ultrasound provided on 
July 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an out-of-network nephrology visit 
provided on July 28, 2022. 
 
You asked the Plan to waive the copayment for an out-of-network nephrology visit. You say that the Plan told 
you that this provider was in network, but they werent. You feel the copayment should be waived. The Plan 
denied your request. The Plan says this cost sharing was charged 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 $65 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $65 copayment for an out-of-network nephrology visit. This item/service 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 an out-of-network nephrology visit provided on July 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diabetic shoes (A5500) and diabetic molded inserts (A5512).

You asked the Plan to pre-approve diabetic foot orthotics. You say that the requested items should be covered due to having type 1 diabetes and hammer toes with ingrown toenails. The Plan denied your request. The Plan says it is required that you see a MD within 6 months for diabetic management.

Medicare rules state that therapeutic shoes, inserts and/or modifications to therapeutic shoes are covered if all criteria is met.

Records show that you do not meet criteria for coverage of the requested shoes and inserts. Therefore, we decided that the Plan does not have to pre-approve diabetic shoes (A5500) and diabetic molded inserts (A5512).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the complete upper denture (D5110) provided on  
May 9, 2022. 
 
You asked the Plan to pay more for this dental item. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. A 
complete upper or lower denture is covered once every five calendar years at a 50% coinsurance. The Plans 
allowable amount for this dental item was $598 x 50% coinsurance=$299 paid for by the Plan.  
 The Plan contract states that enrollees may be billed by the out-of-network provider for any charged amount 
greater than the payment made by the Plan. Therefore, we decided that the Plan does not have to pay more for 
the complete upper denture (D5110) provided on May 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen equipment provided on March 25, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for oxygen equipment. You say that you would like this to be reimbursed at 80%. 
The Plan denied your request. The Plan says there was no preauthorization by a primary care provider (this is 
different than a referral) for an out-of-network (OON) provider or facility, and this was not an emergency. 
Therefore, the decision is upheld. 
 
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 oxygen equipment provided on March 25, 2022, 
by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 
You asked the Plan to pre-approve Gelsyn-3. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Gelsyn-3. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of Bilateral primary osteoarthritis of the knees. The documentation does not 
support that the enrollee has tried and failed Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-One. The 
documentation does not support that Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-One would likely 
be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet 
criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3.