Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services rendered 
from March 5, 2020 to March 8, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that you think the copayment should be 
reduced to one day only. The Plan denied your request. The Plan says the 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 $325 
copayment per day for days 1-5 for in-network inpatient hospital services.  
 
Review of the file shows that you received three days of inpatient hospital services from March 5, 2020 to 
March 8, 2020. You were not assessed a copayment for the date of discharge on March 8, 2020. You have been 
asked to pay a $325 copayment per day for these services, for a total of $975. These services fall within the in-
network inpatient 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. Therefore, we decided that the Plan does not have to waive the copayment for 
the inpatient hospital services rendered from March 5, 2020 to March 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the four crowns provided on January 2, 2020. 
 
You asked the Plan to pay for the crowns. You say that your teeth were exposed to the roots and needed crowns 
to stop the pain. The Plan denied your request. The Plan says the crowns you received are outside of the 
covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. The Plan only covers the recementation of existing crowns. Therefore, 
we decided that the Plan does not have to pay for the four crowns provided on January 2, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for pulmonary function testing provided on 
November 14, 2019. 
 
You asked the Plan to waive the copayment for pulmonary function testing. You say that you disagree with the 
charges because you should only owe $10. The Plan denied your request. The Plan says the claims were 
processed correctly, and you are being charged the correct amount. 
 
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 $225 
copayment for outpatient hospital services.  
 
You have been asked to pay the allowed amount of $151.44, which is less than the $225 copayment for 
pulmonary function testing. Pulmonary function testing 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. Therefore, we 
decided that the Plan does not have to waive the copayment for pulmonary function testing provided on 
November 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on March 2, 2020.
You asked the Plan to pay for the hospital outpatient clinic visit. 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 services 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 a hospital outpatient clinic visit provided on March 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wrist hand orthosis (L3916) provided to the enrollee on 
January 22, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid The Plan denied your request. 
The Plan says documentation submitted did not indicate the provider discussed the need for the billed supply 
code; therefore the billed supply code cannot be verified. 
 
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 orthosis. Our reviewer says that the 
enrollee does not meet criteria for the orthosis ordered. Our physician reviewer found the documentation in the 
case file does not support that a wrist/hand orthosis was medically reasonable and necessary for the enrollee in 
this case. An appropriate history and a physical examination of the wrist would reasonably be required to 
assess whether the wrist/hand orthosis was medically reasonable and necessary. The documentation does not 
support that the wrist/hand orthosis was medically reasonable and necessary in this case, as there is no 
documentation of a wrist problem, nor a documented physical examination of the wrists. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for wrist hand orthosis (L3916) provided to the enrollee on January 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on February 11, 
2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
the health plan requires prior authorization for skilled nursing care. 
 
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 
services 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 February 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on January 6, 2020. 
 
You asked the Plan to pay for the hospital outpatient clinic visit. 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 
services 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 a hospital outpatient clinic visit provided on January 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on April 
3, 2020. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that you believed that 
anything related to Covid was covered. The Plan denied your request. The Plan says that they processed the 
claim in accordance with the Evidence of Coverage. 
 
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 each one-way Medicare-covered ambulance transport.  
 
You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls 
within the one-way Medicare-covered ambulance transport 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 ambulance transport provided on April 3, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SNF stay provided from January 3, 2020 
to January 24, 2020. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you were informed that you would be 
discharged before you would owe a copayment. The Plan denied your request. The Plan says the claims were 
processed correctly, and you are being charged the correct amount. 
 
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 $0 
copayment for days 1-20 and a $178 copayment for days 21-100 for SNF care. 
 
You had a SNF stay from January 3, 2020 to January 24, 2020. Therefore, you are not responsible to pay a 
copayment for days 1-20 (January 3, 2020 to January 22, 2020). You are responsible to pay a $178 copayment 
for day 21 (January 23, 2020). You are not being charged a copayment for the day you were discharged 
(January 24, 2020).   
 
You have been asked to pay a $178 copayment for a SNF stay. A SNF stay falls within the SNF 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 SNF stay provided from January 3, 2020 to 
January 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit provided on April 23, 2020.
You asked the Plan to waive the copayment for urgent care visit. You say that you were not aware of this copayment. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 copayment for urgent care visit. You have been asked to pay $20 copayment for urgent care visit. Urgent care visit falls within the Urgently Needed 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 urgent care visit provided on April 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the stent procedure provided on April 8, 2019. 
 
You asked the Plan to waive the copay for the services provided. You say that the previous procedures did not 
require a copay The Plan denied your request. The Plan says the copay was applied based on your plan. 
 
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 $150 
copay for each visit to an outpatient hospital facility for outpatient surgery.  
 
You have been asked to pay a $150 copay for the services provided. The services fall within the outpatient 
surgery benefit category. The documentation does not show that you were admitted as an inpatient for the 
services at issue. 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 copay for the stent procedure provided on April 
8, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Part B injections provided from 
February 2, 2020 through February 6, 2020. 
 
You asked the Plan to waive the coinsurance for the Part B injections. You say that you cannot afford these 
payments. The Plan denied your request. The Plan says that you are responsible for the coinsurance. 
 
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% 
coinsurance for Medicare-covered Part B prescription drugs, including chemotherapy drugs.  
 
You have been asked to pay a 15% coinsurance for the Part B injections. The Part B injections falls within the 
Medicare-covered Part B prescription drugs, including chemotherapy 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 waive the coinsurance for the Part B injections provided from February 2, 2020 through 
February 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the specialist services provided on April 23, 2020.
You asked the Plan to waive the copay for the services provided. You say that you should not be charged a copay for an electrocardiogram. The Plan denied your request. The Plan says the claim was processed 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 copay per visit to a specialist. You have been asked to pay a $35 copay for the services provided. The services fall within the physician services benefit category. The records show that you were charged for the office visit. You were not charged a copay for the electrocardiogram. 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 copay for the specialist services provided on April 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral 
periapical x-ray, bitewings, comprehensive oral evaluation, and prophylaxis provided on January 28, 2020 and 
February 12, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, 
bitewings, comprehensive oral evaluation, and prophylaxis. You say that you told the provider on each date of 
service not to do anything that was not covered, and to stay within the what the $15 copay covers. You also say 
that you paid $15 each time and do not feel you should have to pay more. The Plan denied your request. The 
Plan says the cost sharing was applied correctly to the services you received. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. The contract clearly states that you are responsible for a $15 copay for 
an oral exam and cleaning, and you are also responsible for a $15 copay for each x-ray provided. Therefore, we 
decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral 
periapical x-ray, bitewings, comprehensive oral evaluation, and prophylaxis provided on January 28, 2020 and 
February 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (CPT 70470) provided to the enrollee on
March 16, 2020.
You asked the Plan to pay for the services. You say that the claim was denied as duplicate in error. The Plan
denied your request. The Plan says this is not a separate and distinct service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that CPT code
70470 has a bundled relationship with CPT code 70496 and cannot be paid as billed. This code cannot be paid
as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore,
we decided that the Plan does not have to pay for radiology services (CPT 70470) provided to the enrollee on
March 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation and extraction provided on March
10, 2020.
You asked the Plan to pay for the limited oral evaluation and extraction. You say that you paid out of pocket
and want reimbursement. The Plan denied your request. The Plan says payment cannot be issued for services
performed by a provider who has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for
the limited oral evaluation and extraction provided on March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 18, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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. 
 
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 
physician?s 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 physician's services provided on February 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a back brace (L0650) provided October 
30, 2019. 
 
You asked the Plan to waive the coinsurance for the brace. You say that the coinsurance should be waived. The 
Plan denied your request. The Plan says the correct cost-sharing 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 15% 
coinsurance for Durable Medical Equipment.  
 
You have been asked to pay a 15% coinsurance ($203.85) for the brace. The brace falls within the Durable 
Medical Equipment 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 a back brace 
(L0650) provided October 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider on March 5, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services 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 the medical services provided to you by an out-of-network provider on March 
5, 2020.