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

 
We decided that the Plan does not have to waive the copayment for an in-network 
esophagogastroduodenoscopy (EGD) provided on April 14, 2023. 
 
You asked the Plan to waive the copayment for an in-network esophagogastroduodenoscopy (EGD). You say 
that this was ordered by your primary care provider, and should be covered. This copayment seems excessive. 
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 
$423.17 copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical 
center, including but notlimited to hospital or other facility charges and physician or surgical charges.  
You have been asked to pay a $423.17 copayment for an in-network esophagogastroduodenoscopy (EGD). 
This item/service falls within the Medicare-covered surgery or other services provided to you at an ambulatory 
surgical center, including but notlimited to hospital or other facility charges and physician or surgical charges 
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. 
However, since the allowed amount is less than the standard copayment, you only owe $423.17. Therefore, we 
decided that the Plan does not have to waive the copayment for an in-network esophagogastroduodenoscopy 
(EGD) provided on April 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network continuous positive airway 
pressure (CPAP) provided on January 23, 2023. 
 
You asked the Plan to waive the coinsurance for an in-network continuous positive airway pressure (CPAP). 
You say that you should not have a copayment for this item. 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 (DME) and related supplies. 
 
You have been asked to pay 20% coinsurance for an in-network continuous positive airway pressure (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. The total you owe is $9.01 
($45.06 allowed per visit x 20% = $9.01). Therefore, we decided that the Plan does not have to waive the 
coinsurance for an in-network continuous positive airway pressure (CPAP) provided on January 23, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission is medically necessary. The Plan denied 
your request. The Plan says the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network primary care visit provided 
on June 26, 2023. 
 
You asked the Plan to waive the copayment for an in-network primary care visit. You say that this was your 
annual physical and should not have a 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 $10 
copayment for Physician/Practitioner services, including doctors office visits. 
 
You have been asked to pay a $10 copayment for an in-network primary care 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 in-network primary care visit provided on June 26, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ambulance response and treatment with no transport 
provided on May 20, 2023. 
 
You asked the Plan to pay for an ambulance response and treatment with no transport. You say that you got 
food poisoning on May 20, 2023. You also say your condition was very weak, so you called 911 for help. The 
Plan denied your request. The Plan says non-transports by an ambulance are not covered by Medicare or your 
Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
 
  The ambulance company did not provide transport services on May 20, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for an ambulance response and treatment with no 
transport provided on May 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a cone beam computed tomography (CT) scan provided 
on June 6, 2023.  
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
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. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service on the appealed claim 
with June 6, 2023. Therefore, we decided that the Plan does not have to pay more for a cone beam computed 
tomography (CT) scan provided on June 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on June 08, 2023. 
 
You asked the Plan to pay for laboratory testing. You say that this is medically necessary and needs to be 
approved. 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 testing 
provided on June 08, 2023.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
You asked the Plan to pre-approve an MRI. You say that this is medically necessary. The Plan denied your request. The Plan says that these services are not medically necessary.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an MRI of the lumbar spine. Our Medical Director states that there is limited history is provided in the clinical notes. Your medical history included prostate cancer and multiple neck and lumbar surgeries. The pain had been present for 3 weeks. Numbness is noted. The severity of pain is not documented, nor is any treatment that may have been trialed. The physical examination at that time did not include motor, sensory, or reflex exams of the extremities. The clinical documentation provided is limited and is insufficient to support that an MRI of the lumbar spine was medically reasonable and necessary for you in this case. Our Medical Director found that your condition does not meet criteria for coverage of an MRI of the lumbar spine.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the betamethasone acetate injection, and 
the joint injection provided by an in-network provider on May 17, 2023. 
 
You asked the Plan to waive the copayment for the injections. You say that the costs are 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 $40 
copayment for each in and out-of-network Medicare-covered Part B drug and non-chemotherapy drugs to treat 
cancer, and a $20 copayment for in and out-of-network services from a specialist or under certain 
circumstances, treatment by a nurse practitioner, physicians assistant, or other non-physician health care 
professional in a specialists office. 
 
You have been asked to pay a $40 copayment for the betamethasone acetate injection. This item/service falls 
within the Medicare Part B prescription drugs benefit category. You have also been asked to pay a $20 
copayment for the joint injection. 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 the betamethasone 
acetate injection, and the joint injection provided by an in-network provider on May 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory test provided on April 03, 
2023. 
 
You asked the Plan to waive the copayment for the laboratory test. You say that you have never had to pay for 
a lipid panel before, and it should be considered routine and have no 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 $15 
copayment for in-network outpatient lab tests. 
 
You have been asked to pay a $15 copayment for the laboratory test. This item/service falls within the in-
network outpatient lab tests 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. However, since the allowed amount is less than the standard copayment, you only owe 
$13.39. Therefore, we decided that the Plan does not have to waive the copayment for the laboratory test 
provided on April 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an office visit and the cochlear implant 
services provided on May 18, 2023. 
 
You asked the Plan to waive the coinsurance for an office visit and the cochlear implant services. You say that 
this service has been fully covered 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 50% 
coinsurance for out-of-network physician/practitioner services, including doctors office visits. 
 
You have been asked to pay 50% coinsurance for an office visit and the cochlear implant services. This item/service falls within the out-of-network 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 coinsurance for an office visit and the cochlear 
implant services provided on May 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on March 29, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you are requesting reconsideration of the 
denied claim. 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 the laboratory service 
provided on March 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
April 26, 2023, to May 01, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you are disputing the 
cost share for these services. 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 in-network emergency care. 
 
You have been asked to pay a $90 copayment for the inpatient hospital stay. This item/service falls within the 
in-network 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. The record shows the enrollee is only being asked to pay the emergency room visit 
copayment. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital 
stay provided on April 26, 2023, to May 01, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve the medication. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says the medication is not covered as a medical benefit under 
the Plan. 
 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 Ozempic.  
 
Benefits for the medication 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is unsafe to be at home needing inpatient 
rehabilitation stay will prevent any risk of injury in the enrollee's home environment by doing intensive 
therapy. The Plan denied your request. The Plan says the records do not show the enrollee will reasonably be 
expected to improve in a short amount of time. The Plan says that the services needed may be provided safely 
in a lower level of care.  
 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit evaluation provided on May 06, 2023. 
 
You asked the Plan to pay for home visit evaluation. You say that you say that medical records are attached to 
support medical necessity. 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 home visit evaluation 
provided on May 06, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill (SSBCI).
You asked the Plan to pre-approve SSBCI benefits. You say that you believe you are eligible for the SSBCI benefits. The Plan denied your request. The Plan says that the criteria for eligibility have not been met. that the criteria for eligibility have not been met.Maximus overturned the Plan's denial because they did not include the relevant EOC. The Plan has requested a reopening and now provided the 2023 Evidence of Coverage for review.
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a documented chronic condition that is life threatening or significantly limits the health or function of the enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an eligible condition that meets all the required criteria. Your physician confirmed that you do not need intensive care management. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the IV push and the ptinezumab injection 
provided on May 11, 2023. 
 
You asked the Plan to provide reimbursement for the IV push and the injection. You say that you were told that 
you should not have to pay more than a $200 copayment and would like to be reimbursed. 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 $180 
copayment for outpatient hospital services. Your contract with the Plan also clearly says that you must pay 
20% coinsurance for Medicare-covered Part B drugs. 
 
You have been asked to pay a $180 copayment for the IV push. This item/service falls within the outpatient 
hospital services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan.  
 
You have also been asked to pay $1,020.48, which is 20% coinsurance of the allowed amount for the injection 
($5,102.48 allowed amount x 20% = $1,020.48). 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 provide reimbursement for the IV push and the 
ptinezumab injection provided on May 11, 2023.