Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the folding walker provided on February 3, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for folding walker. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 folding walker at issue in this appeal. The Plan did not pre-approve the 
folding walker at issue. We found no exception that would require the Plan to pay for the folding walker. 
Therefore, we decided that the Plan does not have to pay for the folding walker provided on February 3, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on April 18, 
2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you should only be charged 
a $45 copayment. The Plan denied your request. The Plan says the copayment applied 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 $45 
copayment for specialist office visit.  
 
You have been asked to pay $45 copayment for specialist office visit. Specialist office visits fall within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for specialist office visit provided on April 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy and other part B drugs 
provided on April 18, 2022 
 
You asked the Plan to waive the coinsurance for chemotherapy and other part B drugs. You say that you should 
not have a payment this high. The Plan denied your request. The Plan says the coinsurance applied was 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 a 20% 
coinsurance for Medicare Part B prescription drugs. The allowed amount of this drug is $8550.42 resulting in a 
coinsurance amount of $1,710.08 ($8550.42 x 20% = $1,710.08). 
 
You have been asked to pay a $1,710.08 coinsurance for chemotherapy and other part B drugs. Chemotherapy 
and other part B drugs fall within the Medicare Part B Prescription Drugs benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for chemotherapy and other part B drugs provided on April 18, 2022
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular reeducation (97112), self-care 
management training (97535), and the gait training therapy (97116) rendered by the out-of-network (OON) 
provider from April 15, 2022, through April 20, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out-of-
network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided 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 neuromuscular reeducation (97112), self-care management training (97535), 
and the gait training therapy (97116) rendered by the out-of-network (OON) provider from April 15, 2022, 
through April 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulmonary diagnostic testing provided on January 19, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the pulmonary diagnostic testing. You say that the provider told you they were 
in-network with the Plan, and you would like a reversal of the denied claim. The Plan denied your request. The 
Plan says the rendering provider is an OON provider and there was no referral from an in-network provider or 
an 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 the pulmonary diagnostic testing provided on 
January 19, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services provided on September 14, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the x-ray services. You say that the services were performed at the enrollee's 
residence, and you were unaware an authorization was needed. The Plan denied your request. The Plan says the 
rendering and referring providers are both OON providers and there was no approved authorization. Also, the 
services rendered were 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 the x-ray services provided on September 14, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections on March 11, 2022. 
 
You asked the Plan to waive the coinsurance for injections. You say that the services should be cover because 
this charge is half of your monthly wages. The Plan denied your request. The Plan says the cost sharing 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 a 20% 
coinsurance for Medicare Part B chemotherapy prescription drugs. These drugs are covered under Part B of 
Original Medicare. Members of our plan receive coverage for these drugs through our plan. Covered drugs 
include chemotherapy. The provider billed in the amount of $47,349.20 and the allowed amount is $6,981.72. 
$6,981.72 x 20% = $1,396.34. The provider also billed in the amount of $29,873.53 and the allowed amount is 
$4,772.16. $4,772.16 x 20% = $954.43. $1,396.34 + $954.43 = $2,350.77. Therefore, results in the total cost 
sharing amount of $2,350.77. 
 
 
 You have been asked to pay a 20% coinsurance for injections. Injections fall within the Medicare Part B 
prescription drugs benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for injections on March 
11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Part B drugs on September 24, 2021. 
 
You asked the Plan to waive the coinsurance for Part B drugs. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says the cost sharing 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 a 20% 
coinsurance for Medicare-covered Part B chemotherapy drugs and other Part B drugs. These drugs are covered 
under Part B of Original Medicare. Members of our plan receive coverage for these drugs through our plan. 
Covered drugs include  Drugs that usually arent selfadministered by the patient and are injected or infused 
while you are getting physician, hospital outpatient, or ambulatory surgical center services. There were 2 
services, one in the amount of $49.80 x 20% = $9.96 and the other in the amount of $890.10 x 20% = $178.02. 
$9.96 + $178.02 = $187.98. Therefore, results in the total cost sharing amount of $187.98.  
 
 You have been asked to pay a 20% coinsurance for Part B drugs. Part B drugs fall within the Medicare Part B 
prescription drugs benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for Part B drugs on 
September 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to change the copayment of the specialist office visit on December 17, 
2021, to an in-network benefit level that was provided by an out-of-network (OON) provider. 
 You asked the Plan to change the copayment of the specialist office visit. You say that the provider works in 
the same office as your primary care provider, and you would like the Plan to file the claims as an in-network 
provider. The Plan denied your request. The Plan says the proper cost share for an out-of-network provider was 
charged for the service that was rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that enrollees may choose to receive care from out-of-network providers using the Plans Preferred 
Provider Organization (PPO) benefits. 
 
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 $55 
copayment for each Medicare-covered OON specialist visit.  
 
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. You have been asked to pay a $55 
copayment for the OON specialist office visit. The specialist office visit falls within the Physician/Practitioner 
Services, Including Doctors Office Visits benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. We found no exception that would require the Plan to change these 
items/services to an in-network benefit level. Therefore, we decided that the Plan does not have to change the 
copayment of the specialist office visit on December 17, 2021, to an in-network benefit level that was provided 
by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for out of network mental health visit provided 
on October 13, 2021. 
 
You asked the Plan to waive the copayment for mental health visit. You say that you though the provider was 
in network. The Plan denied your request. The Plan says the copayment applied 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 $55 
copayment for each out of network Medicare covered individual or group therapy visit.  
 
You have been asked to pay $55 copayment for mental health visit. Mental health visits fall within the 
Outpatient Mental Health 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 
out of network mental health visit provided on October 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services you received on April 12, 2022. 
 
You asked the Plan to pay for the acupuncture services. You say that you were told that acupuncture services 
were covered. The Plan denied your request. The Plan says these services were not billed with a covered 
diagnosis. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, you did not get acupuncture for chronic low back 
pain.  You received acupuncture for neurogenic bladder.  Neither Medicare nor your Plan covers acupuncture 
for this condition. Therefore, we decided that the Plan does not have to pay for acupuncture services you 
received on April 12, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reimburse you for medical center and hospital services received on 
February 21, 2022. 
 
You asked the Plan to reimburse you for medical center and hospital services. You say that the services were 
urgent due to a possible DVT while on a cruise ship. The Plan denied your request. The Plan says that the 
provider was excluded from participating in Federal programs at the time the services were performed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided documentation to support their denial. Therefore, we 
decided that the Plan has to reimburse you for medical center and hospital services received on 
February 21, 2022.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay from December 13, 2021, 
to December 17, 2021. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you should not need to pay this 
copayment. The Plan denied your request. The Plan says the copayment applied was 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 a $370 
copayment per day for days 1 to 4 for inpatient hospital care ($375 x 4 days = $1480) .  
 
You have been asked to pay a $1480 copayment per day for days 1 to 4 for an inpatient stay. an 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 
an inpatient stay from December 13, 2021, to December 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the trastuzumab injection provided on 
February 1, 2022. 
 
You asked the Plan to waive the cost share for the trastuzumab injection. You say that social security is your 
only income, and you cannot afford these bills. 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 20% 
coinsurance for Part B drugs.  
 
You have been asked to pay $426.68, which is 20% of the allowed amount for Part B drugs ($2133.41 the 
allowed amount x 20% coinsurance = $426.68). The trastuzumab injection falls within the Medicare Part B 
Prescription Drugs benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for the trastuzumab 
injection provided on February 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a Botox injection provided on May 10, 
2022. 
 
You asked the Plan to waive the copayment for a Botox injection. You say that you have not been charged this 
copayment before and feel you should not have to pay it now. The Plan denied your request. The Plan says the 
copayment applied was 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 a $295 
copayment for in-network outpatient hospital visit.  
 
 
 
 
 
 
 You have been asked to pay a $295 copayment for a Botox injection. A Botox injection falls within the In-
Network Outpatient Hospital 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 
Botox injection provided on May 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room admission provided on 
February 3, 2022. 
 
You asked the Plan to waive the copayment for an ER admission. You say that you feel you should not have to 
pay this copayment, even though you were transferred from one ER facility to another. The Plan denied your 
request. The Plan says the copayment applied was 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 a $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for an ER admission. An ER admission 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 copayment for an emergency room 
admission provided on February 3, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound scan of head and neck 
provided on November 19, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you would like the Plan to review 
your medical bill. 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 $110 
copayment for radiological diagnostic services.  
 
 
 
 
 
 You have been asked to pay the allowed amount of $104.41, which is less than the $110 copayment for an 
ultrasound. You have already paid $15, leaving a balance of $89.41. An ultrasound 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 the ultrasound scan of head and neck provided on November 19, 2021.