Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for continuous positive airway pressure 
(CPAP) on February 10, 2023, to February 22, 2023.  
 
You asked the Plan to waive the coinsurance for CPAP. 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 20% 
coinsurance for the total cost for Medicare-covered durable medical equipment and related supplies. Covered 
items include, but are not limited to: wheelchairs, crutches, powered mattress systems, diabetic supplies, 
hospital beds ordered by a provider for use in the home, IV infusion pumps, speech generating devices, oxygen 
equipment, nebulizers, and walkers. For date of service February 10, 2023, the provider billed in the amount of $343.80 and the allowed amount is 
$246 for the service. $246 x 20% = $49.20. The provider billed in the amount of $6.50 and the allowed amount 
is $5.00 for the service. $5.00 x 20% = $1.00. The provider billed in the amount of $17.00 and the allowed 
amount is $12.50 for the service. $12.50 x 20% = $2.50. The provider billed in the amount of $17.60 and the 
allowed amount is $12.40 for the service. $12.40 x 20% = $2.48. For date of service February 14, 2023, the 
provider billed in the amount of $106.92 and the allowed amount is $26.40 for the service. $26.40 x 20% = 
$5.28. For date of service February 16, 2023, the provider billed in the amount of $3.40 and the allowed 
amount is $2.50 for the service. $2.50 x 20% = $0.50. For date of service February 22, 2023, the provider billed 
in the amount of $9.10 and the allowed amount is $7.00 for the service. $7.00 x 20% = $1.40. For the services 
it's, $49.20 + $1.00 + $2.50 + $2.48 + $5.28 + $0.50 + $1.40 = $62.36. Therefore, results in the total cost 
sharing amount of $62.36. 
 
You have been asked to pay a 20% coinsurance for CPAP. This item/service 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 continuous positive airway pressure (CPAP) on February 10, 2023, to February 22, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the PET scan and the diagnostic injection 
drug provided on March 15, 2023. 
 
You asked the Plan to waive the coinsurance for the PET scan and the injection. You say that you disagree with 
the coinsurance. 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 4% 
coinsurance for each in-network outpatient hospital visit.  
 
 
 
 You have been asked to pay $69.04, which is 4% coinsurance of the allowed amount for the PET scan 
($1,725.92 allowed amount x 4% = $69.04). You have also been asked to pay $236.91, which is 4% 
coinsurance of the allowed amount for the injection ($5,922.67 allowed amount x 4% = $236.91). These 
items/services fall within the advanced imaging 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 PET scan and the diagnostic injection drug provided on March 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the physical therapy provided on April 12, 
2023. 
 
You asked the Plan to waive the copayment for the physical therapy. You say that this copayment is too 
expensive. 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 in-network outpatient rehabilitation services. 
 
You have been asked to pay a $40 copayment for the physical therapy. This item/service falls within the in-
network 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 the physical therapy provided on April 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Coflex device insertion. 
 
You asked the Plan to pre-approve the Coflex device insertion. You say that the enrollee is getting worse with 
pain and instability, which is affecting their quality of life. The Plan denied your request. The Plan says this 
device is considered experimental and investigational. 
 
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 Coflex device insertion. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that current evidence-based medical guidelines and peer-reviewed literature 
do not fully support the spinal decompression device procedure over the standard lumbar laminectomy. There 
is a lack of large-volume, long-term peer-reviewed outcome studies to support the use of this device for the 
enrollees medical condition. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception to guidelines. 
 
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 Coflex device insertion have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Coflex device insertion.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ganglion cyst removal surgery provided on February 16, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for ganglion cyst removal surgery. You say that you were told approval was given. 
The Plan denied your request. The Plan says the service was not authorized 
 
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 ganglion cyst removal surgery provided on 
February 16, 2023, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radio-frequency ablation (64628, 64629).  
 
You asked the Plan to pre-approve radio-frequency ablation. You say that you are requesting reconsideration of 
the denied authorization. The Plan denied your request. The Plan says this procedure is not medically 
necessary. 
 
We reviewed the Local Coverage Determination (L39420) cited by the Plan and found it was not applicable to 
the jurisdiction. 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 radio-frequency ablation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that this is considered an experimental/investigational procedure at this time. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radio-frequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radio-frequency ablation (64628, 64629).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on February 03, 2023. 
 
You asked the Plan to pay for a home visit. You say that the provider was not responsible for obtaining 
authorization. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home visit provided on 
February 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the telehealth visits provided from 
February 26, 2022, to January 6, 2023. 
 
You asked the Plan to waive the copayments for the telehealth visits. You say that you have never seen this 
provider before. 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 $5 
copayment for in-network medical care provided by a primary care provider.  
 You have been asked to pay a $5 copayment for each telehealth visit provided on February 26, 2022, May 6, 
2022, July 5, 2022, September 9, 2022, October 10, 2022, December 6, 2022, and January 6, 2023. The total 
amount you owe is $35 ($5 copayment x 7 visits = $35). These items/services fall 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 copayments for the telehealth visits provided from February 26, 2022, to January 6, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for biopsy provided on February 06, 2023, by an out-of-network 
(OON) provider.  
 
 You asked the Plan to pay for biopsy. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of the plans network) will not be covered.  
 
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 biopsy provided on February 06, 2023, by an out-
of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the removal of the recurring cataract 
procedure provided by an in-network provider on January 10, 2023. 
 
You asked the Plan to waive the deductible for the cataract procedure. You say that you think that the cost 
sharing should be lower. 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. Your 
contract with the Plan says that there is a $475 deductible which applies to outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers.  
 
 
 
 
 
 You have been asked to pay a $330.86 deductible for the cataract procedure. The item or service you asked the 
Plan to waive the deductible for falls within the outpatient surgery, including services provided at hospital 
outpatient facilities and ambulatory surgical centers benefit category. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $475 deductible which applies to outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers. This cost sharing is a 
contractual obligation that had not been met at the time the cataract procedure was performed on January 10, 
2023. Therefore, we decided that the Plan does not have to waive the deductible for the removal of the 
recurring cataract procedure provided by an in-network provider on January 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on September 13, 2022, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for podiatry services. You say that the provider is an in-network provider. The Plan 
denied your request. The Plan says the service was not authorized. 
 
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 podiatry services provided on September 13, 2022, 
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 a total hip arthroplasty procedure provided 
on February 28, 2023. 
 
You asked the Plan to waive the copayment for a total hip arthroplasty procedure. You say that you cannot 
afford the copayment. 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 $330 
copayment for in-network outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers. 
 
You have been asked to pay a $330 copayment for a total hip arthroplasty procedure. This item/service falls within the in-network outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a total hip 
arthroplasty procedure provided on February 28, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee cannot self-administer injections 
at home. The Plan denied your request. The Plan says that step therapy requirements have not been met. 
 
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 the medication. Our reviewer says that 
the criteria for coverage of Leqvio have not been met. Our physician reviewer found the Plan requires a trial of 
drug Repatha before they will approve Leqvio. In this case, the enrollee has not tried and failed the required 
drug. There is no documentation provided indicating that the Plan's required drug would likely be less effective 
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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Leqvio.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided on January 11, 
2023, to March 21, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for outpatient mental health services. You say that the service was medically 
necessary. The Plan denied your request. The Plan says the service was not authorized. 
 
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 outpatient mental health services provided on 
January 11, 2023, to March 21, 2023, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
February 12, 2023. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not have to 
pay since this was a side effect from a previous surgery. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for the emergency room visit. This item/service falls within the 
emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room visit 
provided on February 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
March 01, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you would like to appeal 
this copayment. 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 $35 
copayment for in-network specialist physician/practitioner services. 
 
You have been asked to pay a $35 copayment for the specialist office visit. This item/service falls within the 
in-network specialist physician/practitioner 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 the specialist office visit provided on March 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 10, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that the services provided should be covered. The Plan 
denied your request. The Plan says the service was not authorized. 
 
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 February 10, 2023, by 
an out-of-network (OON) provider.