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

 
We decided that the Plan has to pay for a computerized corneal topography, unilateral or bilateral, with 
interpretation and report provided on November 10, 2021. 
 
You asked the Plan to pay for a computerized corneal topography, unilateral or bilateral, with interpretation 
and report. You say that before you made an appointment for a consultation for cataract surgery with this 
provider, you verified with the Plan's website that this provider was in-network. The Plan denied your request. 
The Plan says that the Plan does not cover out-of-network vision care. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for a computerized corneal topography, unilateral or bilateral, with interpretation and report 
by the Plan. The file does not show that the Plan provided notice that a computerized corneal topography, 
unilateral or bilateral, with interpretation and report would not be covered. Under Medicare rules, this means a 
computerized corneal topography, unilateral or bilateral, with interpretation and report is considered approved 
by the Plan. Additionally, this service was not a routine vision exam. This service was a medical eye exam. 
Therefore, we decided that the Plan has to pay for a computerized corneal topography, unilateral or bilateral, 
with interpretation and report provided on November 10, 2021.  
 
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 pay for a specialist office visit provided on June 21, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the specialist office visit. You say that services were provided to the enrollee out 
of medical necessity. The Plan denied your request. The Plan says the rendering and referring providers are 
both out-of-network providers and there was no approved authorization. Also, the service rendered was not 
urgent or emergent. 
 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 had network providers 
available who could have provided 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 a specialist office visit provided on June 21, 2021, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a LT wrist-hand orthosis (L3908) and a 
RT wrist-hand orthosis (L3908) provided on November 30, 2021. 
 
You asked the Plan to waive the coinsurance for a LT wrist-hand orthosis and a RT wrist-hand orthosis. You 
say that the provider told you that Medicare would be covering the item themselves. The Plan denied your 
request. The Plan says you were charged the correct cost sharing 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 20% of 
the total cost for Medicare-covered durable medical equipment and related supplies.  
 
You have been asked to pay $17.70 in coinsurance, which is 20% of allowed amount for a LT wrist-hand 
orthosis and a RT writs-hand orthosis ($88.52 allowed amount x 20% coinsurance = $17.70). A LT wrist-hand orthosis and a RT wrist-hand orthosis fall within the Medicare-covered 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 a LT wrist-hand orthosis 
(L3908) and a RT wrist-hand orthosis (L3908) provided on November 30, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the emergency room visits provided on 
October 12, 2021, and October 20, 2021. 
 
You asked the Plan to waive the copayments for the emergency room visits. You say that you were told the 
copayment would be discounted by the provider. The Plan denied your request. The Plan says the proper 
copayments were applied for each date 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 a $90 
copayment for each emergency room visit. The total amount charged for both copayments was $180 ($90 
copayment + $90 copayment). 
 
  You have been asked to pay a $180 copayment for both emergency room visits. The emergency room visits 
falls within the 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. Therefore, we decided that the Plan does not have to waive the copayments for 
the emergency room visits provided on October 12, 2021, and October 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral facet injections. 
 
You asked the Plan to pre-approve bilateral facet injections. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are 
allowed per session per spine region. 
 
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 bilateral facet injections. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the medical record provided 
does not document unique circumstances to support the medical necessity of more than a two-level procedure 
at this time. The elements of the coverage criteria are not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bilateral facet injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bilateral facet injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physician office visit (99215, G2212) and monitored drug 
administration (J3490) provided on September 13, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for a physician office visit and monitored drug administration. You say that the 
services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules 
for payment for out-of-network care have not been met. 
 
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 had network providers 
available who could have provided 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 a physician office visit (99215, G2212) and 
monitored drug administration (J3490) provided on September 13, 2021, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Durable Medical Equipment (DME), a 
shoulder orthosis, on June 15, 2021. 
 
You asked the Plan to waive the coinsurance for Durable medical equipment (DME). You say that you didnt 
have shoulder work done. The Plan denied your request. The Plan says the 20% coinsurance 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% 
coinsurance for Durable medical equipment (DME). The allowed amount of the shoulder orthosis is $103.86, 
resulting in a coinsurance amount of $20.77. 
 
You have been asked to pay 20% coinsurance for Durable medical equipment (DME). A shoulder orthosis 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 Durable Medical Equipment (DME), a shoulder orthosis, on June 15, 2021.
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 November 2, 2021. 
 
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 $250 for 
each one-way Medicare-covered ambulance transport in and out-of-the service area.  
 
 You have been asked to pay a $250 copayment for the one-way Medicare-covered ambulance transport 
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. Therefore, we 
decided that the Plan does not have to waive the copayment for the ambulance transportation service (A0427) 
provided on November 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99214) provided on 
October 25, 2021. 
 
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 no coinsurance, copayment, or deductible for an 
annual wellness visit. If you receive services that address a medical condition during the same office visit, 
additional cost-share may apply. Additionally, you must pay $10 for each covered visit or consultation in an 
outpatient location with your primary care physician (PCP) or other primary care provider.  
 
You have been asked to pay a $10 copayment for the office visit provided. A copayment of $15 was originally 
applied to this service but has now been reduced by the Plan accordingly. Additionally, on this day, you had an 
annual wellness visit which applied a $0 copayment. However, during this visit chronic medical conditions 
were addressed with the provider. The Plan contract states that if you receive services that address a medical 
condition during the same office visit, additional cost-share may apply. 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 (99214) provided on October 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services provided 
on April 7, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the ambulance 
driver stated that you would be arrested if you did not use the services. The Plan denied your request. The Plan 
says you have been charged the correct cost sharing 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 $300 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $300 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
ambulance transportation services provided on April 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
abdomen and pelvis (74178) provided on December 6, 2021. We also decided that the Plan does not have to 
waive the coinsurance for a Medicare Part B injection also provided on December 6, 2021. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan of the abdomen and pelvis 
(74178). You also asked the Plan to waive the coinsurance for a Medicare Part B injection. You say that you 
have never had to pay $100 for a CT scan. The Plan denied your request. The Plan says you were charged the 
correct cost sharing 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 $100 
copayment for diagnostic radiology (CT scan). Your contract with the Plan also says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a $100 copayment for a computed tomography (CT) scan of the abdomen and 
pelvis (74178). A computed tomography (CT) scan of the abdomen and pelvis (74178) falls within the 
outpatient diagnostic tests and therapeutic services and supplies benefit category. You have also been asked to 
pay $2.43 in coinsurance, which is 20% of the allowed amount for a Medicare Part B injection ($12.14 allowed 
amount x 20% coinsurance = $2.43). A Medicare Part B injection falls under 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 waive the copayment for a computed tomography (CT) 
scan of the abdomen and pelvis (74178) provided on December 6, 2021. We also decided that the Plan does not 
have to waive the coinsurance for a Medicare Part B injection also provided on December 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve surgical services. You say that the enrollee is experiencing chronic pain and 
the services are necessary to correct this. The Plan denied your request. The Plan says the enrollee must receive 
care from an in-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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
surgical services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) cardiologist. 
 
You asked the Plan to pre-approve an office visit. You say that you have lost confidence in the doctor you were 
seeing and want to see a new one. The Plan denied your request. The Plan says the provider you want to see is 
out-of-network and you must receive your care from a 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) cardiologist.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
November 1, 2021, to November 6, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were not aware of 
the copayment being so high and thought everything would be covered once you were admitted. The Plan 
denied your request. The Plan says the proper copayment was applied for the 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 a $325 
copayment per day for days 1 through 6 per benefit period. The total copayment amount for the dates of service 
was $1,625 ($325 copayment x 5 days). 
 
  You have been asked to pay a $1,625 copayment for the inpatient hospital stay. The 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 provided from November 1, 2021, to November 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray of the chest (71046) provided on 
October 14, 2021. 
 
You asked the Plan to waive the copayment for an x-ray of the chest. You say that there should be no 
copayment for diagnostic radiology services per the Plan coverage. The Plan denied your request. The Plan 
says you were charged the correct cost sharing 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 $15 
copayment for each Medicare-covered standard x-ray service.  
 
 
 
 
 
 You have been asked to pay a $15 copayment for an x-ray of the chest. An x-ray of the chest 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 waive the copayment for an x-ray of the chest (71046) provided on October 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a positron emission tomography (PET) 
with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization 
imaging, skull base to mid-thigh (78815) provided on November 11, 2021. 
 
You asked the Plan to waive the coinsurance for a positron emission tomography (PET) with concurrently 
acquired computed tomography (CT) for attenuation correction and anatomical localization imaging, skull base 
to mid-thigh. You say that you are appealing. The Plan denied your request. The Plan says you were charged 
the correct cost sharing 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 20% 
coinsurance for each Medicare covered diagnostic radiology.  
 You have been asked to pay $408.29 in coinsurance, which is 20% of the allowed amount for a positron 
emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction 
and anatomical localization imaging, skull base to mid-thigh ($2,041.44 allowed amount x 20% coinsurance = 
$408.29). A positron emission tomography (PET) with concurrently acquired computed tomography (CT) for 
attenuation correction and anatomical localization imaging, skull base to mid-thigh 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 waive the 
coinsurance for a positron emission tomography (PET) with concurrently acquired computed tomography (CT) 
for attenuation correction and anatomical localization imaging, skull base to mid-thigh (78815) provided on 
November 11, 2021.