Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments and coinsurance for a diagnostic injection and 
denosumab administration provided from October 20, 2021, to November 3, 2021. 
 
You asked the Plan to waive the copayments and coinsurance for the injections. You say that you have the 
injections at your PCP's office and you should only have to pay for the pharmacy. The Plan denied your 
request. The Plan says the correct copayments and coinsurance were applied. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 
copayment for surgery or other services provided at an outpatient hospital or ambulatory surgical center. 
 
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for each Part B drug, 
including injectable drugs. 
 
You have been asked to pay $242.59, which is less than the $295 copayment for the diagnostic injection 
provided on October 20, 2021. You have also been asked to pay $57.56, which is also less than the $295 
copayment for the therapeutic injection provided on November 3, 2021. The injections fall within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers benefit category. You have also been asked to pay $185.90 for the Part B drug denosumab provided on 
November 3, 2021, which is 20% of the allowed amount ($929.52 allowed amount x 20% coinsurance = 
$185.90). The denosumab falls within the Medicare Part B Prescription Drugs benefit category. The total for 
both visits is $486.05. 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 and coinsurance for a diagnostic 
injection and denosumab administration provided from October 20, 2021, to November 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve ventilator. You say that you refuse for the enrollee to be redirected to an in-
network provider. The Plan denied your request. The Plan says the denial of authorization for this device is 
correct, because the provider is out-of-network with the Plan and a ventilator can be obtained from an in-
network equipment supplier. 
 
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 a ventilator 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 waive the copayment for an urgent care visit provided on November 
14, 2021. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that your PCP was unable to fill 
your prescription in time and you were forced to go to urgent care. 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 $25 
copayment for urgent care visits.  
 
You have been asked to pay a $25 copayment for the urgent care visit. The 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 November 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the copayment for the outpatient medical services provided 
on September 15, 2021. 
  You asked the Plan to pay for the copayment for the outpatient medical services. You say that you hit your out-
of-pocket expense so the Plan should pay for this service. The Plan denied your request. The Plan says the 
enrollee's out-of-pocket maximum was not met prior to the date of service. Therefore, the proper 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 $250 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges. Prior to the date of 
service, the enrollee paid $3,609.39 of the $3,900 MOOP. The total amount allowed for the service rendered 
was $231.13 which is less than the copayment of $250. Therefore, only $231.13 was charged as the copayment. 
 
You have been asked to pay a $231.13 copayment for the outpatient medical services. The outpatient medical 
services falls within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient 
Facilities and Ambulatory Surgical Centers 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 pay for the copayment 
for the outpatient medical services provided on September 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a breast ultrasound provided on September 
30, 2021, and a breast biopsy provided on October 7, 2021. 
 
You asked the Plan to waive the copayments for a breast ultrasound and biopsy. You say that you are being 
billed for follow up services and your annual exams are always covered. You also say that you were told by the 
insurance company to disregard the charges. 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 $125 
copayment for radiological diagnostic services, including ultrasounds at a freestanding facility. The Plan 
contract also says that enrollees must pay a $35 copayment for services obtained from a specialist.   
 
The record shows the services are not included in your annual mammogram. You have been asked to pay the 
allowed amount of $88.93, which is less than the $125 copayment for a breast ultrasound. A breast ultrasound 
falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. You have 
also been asked to pay a $35 for a breast biopsy. A breast biopsy falls within the Physician/Practitioner 
Services, Including Doctors Office Visits benefit category. You have been asked to pay a total of $123.93 
($88.93 copayment + $35 copayment = $123.93). This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for a 
breast ultrasound provided on September 30, 2021, and a breast biopsy provided on October 7, 2021.  
 
Your complaint about the insurance company telling you to disregard the charges 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on November 23, 
2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that this is a covered service. The Plan 
denied your request. The Plan says the copayment amount 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 $110 
copayment for Medicare-covered radiological diagnostic services, not including X-rays, performed in a 
physician's office or at a free-standing facility (such as a radiology center or medical clinic). The diagnostic 
radiology services require specialized equipment beyond standard X-ray equipment and must be performed by 
a specially trained or certified personnel. Examples include, but are not limited to, ultrasounds.  You have been asked to pay a $108.09, which is less than the Plan's EOC documented $110 copayment for an 
ultrasound. 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 provided on 
November 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit (99326) provided on 
November 10, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the rendering physician is a 
hospitalist physician and depends upon the hospital staff to verify eligibility and to obtain the proper 
authorization from the patient's insurance company. The Plan denied your request. The Plan says they followed 
up with the member's primary care physician office and confirmed there was not a referral on file from the 
billing or rendering provider for the date of service of November 10, 2021. The Plan also says that these 
services were billed by and rendered by providers who were both non-participating providers, and the plan has 
also determined that these services are not urgent or emergent, nor were they approved in advance. 
 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 domiciliary or rest home visit (99326) provided 
on November 10, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 9, 2021, 
November 17, 2021, and December 2, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the referring provider asked you to provide 
the lab services. The Plan denied your request. The Plan says both the rendering and referring providers are 
both out-of-network providers and there was no approved authorization. Also, the services 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 laboratory services provided on November 9, 
2021, November 17, 2021, and December 2, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires a more 
sophisticated level of care. The Plan denied your request. The Plan says the enrollee is receiving appropriate 
inpatient acute care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our physician 
reviewer found that the enrollee was admitted to the acute care hospital with acute abdominal pain. She 
required emergent surgery. Her hospital course was complicated by post-operative anemia. She is receiving 
appropriate care at the present acute care hospital. She does not require services at the LTACH that are not 
available at the acute care hospital where he/she is currently receiving care. There are no services available at 
the LTACH that she requires that are not available at the health care setting being offered by the health plan. 
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the copayment for an ultrasound of the abdomen 
provided on October 25, 2021. 
 
You asked the Plan to waive or reduce the copayment for the ultrasound. You say that the Plan did not pay 
anything on the claim. 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 $150 
copayment for radiological diagnostic services, not including X-rays.  
 
 
 You have been asked to pay $128.04, which is less than the $150 copayment for the ultrasound. The 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 or reduce the copayment for an ultrasound of the abdomen provided on 
October 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on November 12, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advance. 
 
 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 skilled nursing services provided on November 
12, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of a 
lower extremity provided on November 12, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you have Medicaid and you have 
never had to pay for these services in the past. 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 $180 copayment for advanced imaging services 
provided at a PCP or specialist office, or a free-standing radiological facility.  
 
You have been asked to pay $128.20, which is less than the $180 copayment for the CT scan. The CT scan falls 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a computed tomography (CT) scan of a lower extremity provided on 
November 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) provided on 
December 29, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the DME. You say that you would like a different denial so you can bill the 
enrollee's secondary insurance. The Plan denied your request. The Plan says the provider is an out-of-network 
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 durable medical equipment (DME) provided 
on December 29, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on August 26, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says CPT 27511 was not billed in accordance with Medicare National Correct Coding Initiative 
Policy.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 27511 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services 
provided to the enrollee on August 26, 2021.
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 January 18, 
2022. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that you were having COVID-19 
symptoms and there were no home test kits available. 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 $35 
copayment for each office or telehealth urgent care visit with any provider other than your POC.  
 
You have been asked to pay a $35 copayment for the urgent care visit. The 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 January 18, 2022.