Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the primary care provider office visit 
provided on January 10, 2023. 
 
You asked the Plan to waive the copayment for the primary care provider office visit. You say that you have 
not had a cost share for this in the past. 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 
copayment for primary care provider/practitioner services. 
 
You have been asked to pay a $10 copayment for the primary care provider office visit. This item/service falls 
within the primary care provider/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. The records show other services were provided, and the primary 
care provider office visit copayment applies. Therefore, we decided that the Plan does not have to waive the 
copayment for the primary care provider office visit provided on January 10, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the two renflexis injections and the 
administration provided by an in-network provider on December 29, 2022. 
 
You asked the Plan to waive the cost sharing for the injections and the administration. You say that you think 
that the cost sharing is too high. 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 in and out-of-network intravenous, subcutaneous, and biological Part B drugs, and a $300 
copayment for in-network outpatient hospital and ambulatory surgical center visits. 
 
You have been asked to pay a $885.41 coinsurance for the injections ($4427.06 allowed amount for 2 
injections x .20 = $885.41). These items/services fall within the Medicare Part B prescription drugs benefit 
category. You have also been asked to pay a $25 copayment for the administration because the Plan is only 
holding you responsible for this amount, which is less than the $300 copayment. This item/service falls within 
the 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 cost sharing for the two renflexis injections and 
the administration provided by an in-network provider on December 29, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says the services are 
available by a provider in your 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 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the daratumumab injection and drug 
administration provided on December 9, 2022, and December 16, 2022. You asked the Plan to reduce the coinsurance for the daratumumab injection and drug administration. You say 
that the discount price for the drug listed online is much less than what you are 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 20% 
coinsurance for Medicare Part B drugs and drug administration.  
 
You have been asked to pay 20% coinsurance for each daratumumab injection. You have also been asked to 
pay 20% coinsurance for each drug administration service. These items/services fall within the Medicare Part B 
drugs benefit category. Due to meeting your out-of-pocket maximum, you have not been charged the full 20% 
coinsurance on December 16, 2022. 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 reduce the coinsurance for the daratumumab 
injection and drug administration provided on December 9, 2022, and December 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you would like to see the doctor again in 3 
months time for a routine follow-up. The Plan denied your request. The Plan says it is very important to get a 
written referral (approval in advance) from the enrollees primary care physicain (PCP) before the enrollee sees 
a plan specialist or certain other providers (there are a few exceptions, listed in Section 2.2 of Chapter 3). If the 
enrollee doesn't have a written referral (approval in advance) before the enrollee gets services from a specialist, 
the enrollee may have to pay for these services them self. 
 
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 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic visits provided on January 05, 2022, to 
November 07, 2022. 
 
You asked the Plan to pay for chiropractic visits. You say that you thought that your Plan would reimburse you 
for Out-of-Network services. 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 chiropractic visits 
provided on January 05, 2022, to November 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 29, 2022. 
 
You asked the Plan to pay for an office visit. You say that these services are medically necessary. 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 an office visit provided 
on December 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the member's current medical condition 
requires an LTACH admission. The Plan denied your request. The Plan says the LTACH services requested do 
not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
  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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. All medically 
necessary care is being provided in the current acute care setting.  The health plan has approved ongoing care 
in the current acute care setting. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the arthrocentesis and drug injection 
provided on January 13, 2023. 
 You asked the Plan to waive the copayments for the arthrocentesis and drug injection. You say that you should 
not be charged two separate copayments. 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 $15 
copayment for each specialist office visit. Your contract with the Plan also clearly says that you must pay a $15 
copayment for Medicare Part B drugs. 
 
You have been asked to pay a $15 copayment for the arthrocentesis. This item/service falls within the 
physician/practitioner services benefit category. You have also been asked to pay a $15 copayment for the drug 
injection. This item/service falls within the Medicare Part B drugs benefit category. You have been asked to 
pay a total of $30 ($15 copayment + $15 copayment = $30). 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 arthrocentesis and drug injection provided on January 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that you would like reconsideration because the 
requested raised toilet seat is medically necessary. The Plan denied your request. The Plan says "the requested 
raised toilet seat is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on November 18, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services are medically necessary. 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 laboratory services 
provided on November 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each humidifier rental provided on April 
11, 2022, to August 11, 2022. 
 
You asked the Plan to waive the coinsurance for each humidifier rental. You say that you were billed in error. 
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 20% 
coinsurance for durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for each humidifier rental. This item/service falls within the 
durable medical equipment 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. The amount you owe for each humidifier rental is $5.48 ($27.40 
allowed amount x 20% = $5.48). The total amount you owe is $27.40 ($5.48 copayment x 5 humidifier rentals 
= $27.40) Therefore, we decided that the Plan does not have to waive the coinsurance for each humidifier 
rental provided on April 11, 2022, to August 11, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit provided 
on December 27, 2022. 
 
You asked the Plan to waive the copayment for each physical therapy (PT) visit. You say that you were 
unaware of the copayment and are unable to pay for the charges. 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 
copayment for outpatient rehabilitation service.  
You have been asked to pay a $10 copayment for each physical therapy (PT) visit. This item/service falls 
within the outpatient rehabilitation service 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 each physical therapy (PT) visit provided on December 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on August 08, 2022, 
to August 22, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $205 copayment for days 1-6: $205 copay per day (per Medicare-covered stay) which includes day 
of admission and day of discharge. After the 6th day, the plan pays 100% of covered expenses for inpatient 
hospital stay.  Includes inpatient acute, inpatient rehabilitation, long-term care hospitals and other types of 
inpatient hospital services. Inpatient hospital care starts the day you are formally admitted to the hospital with a 
doctors order. The day before you are discharged is your last inpatient day. 6 x $205 = $1,230. $0.01 was not 
covered. Therefore, results in the total cost sharing amount of $1,230.01. 
 
The enrollee has been asked to pay a $205 copayment per day for inpatient hospital stay. This item/service 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 waive the 
copayment for inpatient hospital stay on August 08, 2022, to August 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for out-of-network durable medical equipment 
(DME) provided on January 13, 2022. 
 
You asked the Plan to waive the copayment for out-of-network DME. You say that you disagree with 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. Your 
contract with the Plan says that there is a $500 deductible which applies to out-of-network durable medical 
equipment (DME).  
 
The item or service you asked the Plan to waive the copayment for falls within the out-of-network durable 
medical equipment (DME) benefit category. The total amount you are being asked to pay is $103 towards your 
$500 deductible. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 
deductible which applies to out-of-network durable medical equipment (DME). This cost sharing is a 
contractual obligation that had not been met at the time out-of-network DME was received on January 13, 2022. Therefore, we decided that the Plan does not have to waive the copayment for out-of-network durable 
medical equipment (DME) provided on January 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a LDCT scan for lung cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that you would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says a LDCT is not 
medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that you do not fall within the age range. Therefore, we 
decided that the Plan does not have to pre-approve a LDCT scan for lung cancer screening.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the inpatient hospital care provided on 
December 09, 2022, to December 23, 2022. 
 
You asked the Plan to waive the coinsurance for the inpatient hospital care. You say that you were not advised 
that the facility was out of network. 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 20% 
coinsurance for inpatient hospital care (out-of-network). 
 
You have been asked to pay 20% coinsurance for the inpatient hospital care. This item/service falls within the 
inpatient hospital care (out-of-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. The 20% coinsurance in this case is $5,166.61 ($25,833.05 allowed x 20% 
coinsurance = $5,166.61. However, you only owe $4,071.72 due to meeting your maximum out-of-pocket 
(MOOP). Therefore, we decided that the Plan does not have to waive the coinsurance for the inpatient hospital 
care provided on December 09, 2022, to December 23, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network ambulance ride provided on 
June 28, 2022. 
 
You asked the Plan to waive the copayment for an in-network ambulance ride. You say that you were in an 
accident while in this ambulance. You should not have to pay 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 $200 
copayment for ambulance services. 
 
You have been asked to pay a $200 copayment for an in-network ambulance ride. This item/service falls within 
the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an in-
network ambulance ride provided on June 28, 2022.