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

 
We decided that the Plan does not have to waive the copayment for ambulance services you received on April 
7, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that since you were diagnosed 
with COVID-19 after this service, the copayment should be waived. The Plan denied your request. The Plan 
says you were charged this copayment correctly.  There is no provision for the waiver of copayments related to 
ambulance services.  The Plan says that they are only waiving cost sharing for primary care services, COVID-
19 testing, and doctor visits for COVID-19 treatment. 
 
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 $250 
copayment for ambulance services.  
 
You have been asked to pay a $250 copayment for the ambulance 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 copayment for ambulance services you received on April 7, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the abdominal ultrasound provided on June 
12, 2020. 
 
You asked the Plan to waive the copayment for the abdominal ultrasound. You say that there is no freestanding 
lab or clinic for an ultrasound within 100 miles. You say that the copayment should be reduced or waived. 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 an $85 
copayment for diagnostic procedures and tests at an in-network outpatient hospital.  
 
You have been asked to pay an $85 copayment for the abdominal ultrasound. The abdominal ultrasound falls 
within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records 
show that you were charged the in-network rate for the ultrasound. 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 abdominal ultrasound provided on June 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the posterior interspinous decompression spacer 
procedure for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is not enough medical evidence to support this procedure. 
 
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 procedure. Our reviewer says that 
the requested procedure is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the spacer is experimental. More research is needed to show safety and efficacy of the device. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the posterior interspinous decompression spacer procedure for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a 
participating provider on July 6, 2020. 
 
You asked the Plan to waive the copayment for a biopsy. You say that you were told that your copayment 
would be $30. 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 $350 
copayment for outpatient surgery/outpatient hospital facility.  
 
You have been asked to pay a $350 copayment for a biopsy. A biopsy falls within the outpatient 
surgery/outpatient hospital facility 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 outpatient surgery provided by a participating provider on July 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the osteogenesis stimulator provided on 
June 8, 2020. 
 
You asked the Plan to waive the coinsurance for the osteogenesis stimulator. You say that you were promised 
there would be no charge for the stimulator. You say that you would not have purchased this if you knew there 
would be a charge. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance per Medicare-covered item.  
 
You have been asked to pay $497.40, which is 20% of the allowed amount for the osteogenesis stimulator. The 
allowed amount is $2,487 (20% x $2,487 = $497.40). The osteogenesis stimulator 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 the osteogenesis stimulator provided on June 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay on April 4 to 
April 7, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were not advised at 
enrollment in the Plan that this copayment applies to each admission for inpatient hospital care. 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 $395 
copayment for each day for days 1-4 for Medicare-covered hospital care.  
 
You have been asked to pay $1,185, or a $395 copayment for 3 days of hospital care, for an inpatient hospital 
stay. An inpatient hospital 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 an inpatient hospital stay on April 4 to April 7, 2020.  
 
Your complaint about receiving erroneous or misleading information about cost-sharing from a representative 
of the Plan 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 the office visit provided on July 21, 2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that you are a diabetic and only went 
for routine foot care. You say that there shouldn't have been a 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 $30 
copayment for each Medicare-covered visit (medically necessary foot care). 
 
You have been asked to pay a $30 copayment for the office visit. The office visit falls within the "Podiatry 
services" benefit category. The records show that this was a non-routine 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 July 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to adjust the coinsurance for the evaluation and insertion of catheters for recording, pacing, and treatment of abnormal heart rhythm (93656) provided from May 5, 2020, through May 9, 2020.

You asked the Plan to adjust the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance was applied correctly to the services 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 20% coinsurance for in-network and out-of-network Medicare-covered surgery or other services provided at an outpatient hospital or ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges.


You have been asked to pay $2,606.45 ($20,461.02 Plan allowed amount x 20% coinsurance -$393.55 already paid toward the out of pocket maximum of $3,000) for the Medicare-covered surgery services provided at an outpatient hospital. 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 adjust the coinsurance for the evaluation and insertion of catheters for recording, pacing, and treatment of abnormal heart rhythm (93656) provided from May 5, 2020, through May 9, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for the EEG, including recording awake and asleep, provided on February 
11, 2020. 
 
You asked the Plan to pay for the EEG. You say that the enrollee had recently moved from out of state, and has 
a history of multiple sclerosis. You also say that the enrollee has not been taking his medication because he had 
run out. The Plan denied your request. The Plan says that the service was rendered by a non-participating 
provider in a non-participating facility. The Plan also says that authorization was not obtained. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and 
pre-approved care.   
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the EEG. Our reviewer says that the care 
provided was medically necessary. Our physician reviewer found the enrollee could not have foreseen 
requiring the services prior to leaving his service area. Our reviewer also found that it would not have been 
medically reasonable to delay service until the enrollee returned to his/her service area or up to 6 months. 
 
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 EEG have been met. Therefore, we decided that the Plan has to pay for the 
EEG, including recording awake and asleep, provided on February 11, 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 a specialist office visit provided by a 
participating provider on June 17, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that this was a post-op 
appointment. 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 $35 
copayment for physician/practitioner services/specialist visit.  
 
You have been asked to pay a $35 copayment for a specialist office visit. Post-op office visits are subject to 
copayments; therefore, the correct copayment has been applied. A specialist office visit falls within the 
physician/practitioner services/specialist visit 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 specialist office visit provided by a participating provider on June 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on September 3, 
2019. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on September 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating 
provider on July 20, 2020. 
 
You asked the Plan to waive the copayment for lab work. You say that this was all part of your annual. 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 $20 
copayment for outpatient diagnostic tests/in-network/labs.  
 
You have been asked to pay a $20 copayment for lab work. Lab work goes beyond an annual wellness exam; 
therefore, the correct copayment has been applied. Lab work falls within the outpatient diagnostic tests/in-
network/labs 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 lab work provided by a 
participating provider on July 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmology services provided on January 5, 2020. 
 
You asked the Plan to pay for the ophthalmology services. The Plan denied your request. The Plan says there is 
no valid referral for this service. 
 
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 did not pre-approve the 
ophthalmology services. We found no exception that would require the Plan to pay for these services. 
Therefore, we decided that the Plan does not have to pay for ophthalmology services provided on January 5, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the established patient office or other outpatient visit (99213) 
provided on May 22, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient office or other outpatient visit. 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 established patient office or other outpatient 
visit (99213) provided on May 22, 2020, by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the extremity study (93971) provided on April 28, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the extremity study. You say that the services rendered 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 extremity study (93971) provided on April 28, 
2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis provided on July 30, 2020. 
 
You asked the Plan to pay for the knee orthosis. The Plan denied your request. The Plan says the enrollee must 
receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan.  
 
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 did not pre-approve the 
knee orthosis. We found no exception that would require the Plan to pay for these items. Therefore, we decided 
that the Plan does not have to pay for a knee orthosis provided on July 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit (G0439) provided on February 28, 
2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the annual wellness visit. 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 annual wellness visit (G0439) provided on 
February 28, 2020, by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on July 27, 2020. 
 
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says these 
services are not a covered benefit. 
 
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 July 27, 2020. 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 the ambulance services provided on July 27, 2020.