Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to waive the copayment for laboratory tests provided on April 14, 2020. 
 
You asked the Plan to waive the copayment for laboratory tests. You say that you were charged $45 for each 
visit. You say that you are requesting a reversal of the copayment for the lab visit. The Plan denied your 
request. The Plan says that the copayment applied 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 does not say in clear and accurate terms 
how much you should expect to pay when only laboratory services are performed at a specialist's office. 
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $45 
specialist visit copayment for laboratory services. The Plan contract does not clearly say how much enrollees 
must pay when only laboratory services are provided in a specialist?s office. This means that the Plan did not 
follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to 
waive the copayment for laboratory tests provided on April 14, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on June 25, 2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that you told the doctor you only 
wanted a prescription for new glasses. You say that you never got the prescription. The Plan denied your 
request. The Plan says the copayment applied 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 Medicare-covered eye exams to diagnose and treat diseases and conditions of the eyes. 
 
You have been asked to pay a $35 copayment for the office visit. The office visit falls within the "Vision care" 
benefit category. The records show that a medical eye exam was performed during the visit. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the office visit provided on June 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the CT scan provided on June 10, 2020. 
 
You asked the Plan to reduce the copayment for the CT scan. You say that it is your understanding that your 
copayment is $5. You say that you expect to pay $5 and insurance to pay $107.91. The Plan denied your 
request. The Plan says the copayment applied 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 advanced imaging services at an in-network PCP's office, specialist's office or freestanding 
radiological facility.  
 
You have been asked to pay $112.91, which is less than the standard $180 copayment for the CT scan. The CT 
scan 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 reduce the copayment for the CT scan provided on June 10, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a transvaginal ultrasound (76830) and a 
pelvic ultrasound (76856) performed on May 19, 2020. 
 
You asked the Plan to waive the copayments for a transvaginal ultrasound and a pelvic ultrasound. You say that 
the doctor has 2 codes for this procedure but it was done with one ultrasound exam. The Plan denied your 
request. The Plan says the correct copayments were applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110 
copayment for each Medicare-covered radiological diagnostic service, not including X-rays.  
 
You have been asked to pay a $110 copayment for each of a transvaginal ultrasound and a pelvic ultrasound. A 
transvaginal ultrasound and a pelvic ultrasound fall within the "Outpatient Diagnostic Tests and Therapeutic 
Services and Supplies" benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for a 
transvaginal ultrasound (76830) and a pelvic ultrasound (76856) performed on May 19, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility care provided on October 21, 2019 
and October 31, 2019. 
 
You asked the Plan to pay for the skilled nursing facility care. The Plan denied your request. The Plan says 
Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to 
the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on October 5, 2019. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for skilled nursing 
facility care provided on October 21, 2019 and October 31, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from March 24, 
2020, through March 28, 2020. 
 
You asked the Plan to waive the copayment for the inpatient stay. You say that all the copayments from that 
period should have been waived. You say that you need help with this charge. The Plan denied your request. 
The Plan says the copayment applied 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 $275 
copayment each day for days 1 to 5 for Medicare-covered hospital care. 
 
You have been asked to pay a $1,100 copayment for the inpatient stay. ($275/day x 4 days = $1,100). The 
inpatient stay 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 the inpatient stay provided from March 24, 2020, through March 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the podiatry visit you had on July 28, 2020. 
 
You asked the Plan to waive the copayment for the podiatry visit. You say that you had a routine diabetic foot 
care visit, so there should be no copayment. The Plan denied your request. The Plan says you had services 
beyond a routine diabetic foot care visit, so the podiatry copayment was applied 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 medically necessary foot care services.  
 
As noted above in the Medicare Rules section, routine podiatry visits are limited to the following services: 
cutting or removal or corns and calluses, trimming or debriding of nails, and other hygienic or preventive 
maintenance care (such as soaking of the feet or use of skin creams.)  We looked at the medical records from 
the visit you had on July 28, 2020.  The medical records clearly show that you received services beyond what is 
included in a routine visit.  Specifically, your doctor performed a full work-up on your complaints of foot pain 
in addition to your routine diabetic foot evaluation and toenail debridement.  Because you received these 
additional services, the podiatry copayment was assessed. You have been asked to pay a $40 copayment for the 
podiatry visit. 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 podiatry visit you had on July 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee's current medication list does not include insulin or diabetic oral medication. 
 
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 monitor. Our reviewer says that the 
requested monitor is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the review has determined that the monitor is not considered therapeutic. There is not a diagnosis of 
diabetes mellitus. The enrollee has not been using insulin multiple times (3 or more) a day. The treatment does 
not require frequent adjustment on the basis of testing results. 
 
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 monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a 
participating provider on June 10, 2020. 
 
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you think this is an 
excessive charge for the belt that you were given. The Plan denied your request. The Plan says the correct 
coinsurance has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment/in-network.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The 
total allowed amount is $828.94. The total amount you are being asked to pay is $165.79 ($828.94 x 20% = 
$165.79). The correct coinsurance has been applied to the brace that was provided. Durable medical equipment 
falls within the durable medical equipment/in-network benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the coinsurance for durable medical equipment provided by a participating provider on June 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical nutrition therapy. 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that this is medically necessary. 
The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does 
not have to pre-approve medical nutrition therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic eye exam (92014) received on 
June 30, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic eye exam. You say that this service was your 
annual preventive diabetic eye exam. The Plan denied your request. The Plan says the correct copayment was 
applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for Medicare-covered eye exams to diagnose and treat diseases and conditions of the eyes.  
 
You have been asked to pay a $35 copayment for a diagnostic eye exam. A diagnostic eye exam is distinct 
from a routine diabetic retinal eye exam. A diagnostic eye exam falls within the "Vision 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 a diagnostic eye exam (92014) received on June 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (G0103, 85025, 80053, 83036) 
provided on June 15, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider; therefore, payment has been correctly 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 has network providers 
available who can provide 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 the laboratory services (G0103, 85025, 80053, 
83036) provided on June 15, 2020, by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on October 24, 
2019. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to 
the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on October 5, 2019. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for subsequent nursing 
facility care provided on October 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for physical therapy (PT) services you 
received from an out-of-network provided from January 8, 2020, through February 27, 2020. 
 
You asked the Plan to waive the cost sharing for the PT services. You say that you feel as though this plan 
wasn't explained to you when you signed up, so you don't think you should have to pay this bill. The Plan 
denied your request. The Plan says you were charged the deductible and coinsurance correctly. The plan says 
that you met your deductible as of date of service February 4, 2020, so you were charged coinsurance for later 
dates of service. 
 
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 40% 
coinsurance for out-of-network physical therapy services after your $750 annual deductible is met.  
 
You have been asked to pay the deductible and 40% coinsurance for the PT services. You had not yet met your 
deductible when you began receiving these services, which is why you were charged the full cost until 
February 4, 2020.  After that date, you were charged the applicable 40% coinsurance for out-of-network PT 
services. 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 physical therapy (PT) services you received 
from an out-of-network provided from January 8, 2020, through February 27, 2020.  

Your complaint about how this plan was marketed and sold to you 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a duplex scan provided by a participating 
provider on February 26, 2020. 
 
You asked the Plan to waive the copayment for radiological diagnostic services. You say that you never had to 
pay for this before. You say that this is considered preventative. The Plan denied your request. The Plan says 
the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $155 
copayment for outpatient diagnostic tests/radiological diagnostic services.  
 
You have been asked to pay a $155 copayment for radiological diagnostic services. Radiological diagnostic 
services fall within the outpatient diagnostic tests/radiological diagnostic 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 a duplex scan provided by participating provider on February 26, 
2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation service 
(A0427) provided on May 4, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for each one-way Medicare-covered ground ambulance trip.  
 
You have been asked to pay a $275 copayment for the one-way Medicare-covered ambulance trip provided. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Additionally, the record 
shows that the Plan verified there was no cost share applied for the second ambulance transport provided. 
Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transportation 
service (A0427) provided on May 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the REVISION OF IRIS (66761), EYE EXAM NEW 
PATIENT (92002) and SPECIAL EYE EVALUATION (92020)  provided on February 28, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for eye exam, special eye evaluation and revision of iris. You say that the services 
were medically necessary. The Plan denied your request. The Plan says prior authorization must be obtained 
for non-emergent services rendered by an out-of-network provider. 
 
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 has network providers 
available who can provide 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 the REVISION OF IRIS (66761), EYE EXAM 
NEW PATIENT (92002) and SPECIAL EYE EVALUATION (92020)  provided on February 28, 2020 by an 
out of network (OON) provider.