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

 
We decided that the Plan does not have to waive the copayment for an office visit provided on December 6, 
2021. 
 
You asked the Plan to waive the copayment for an office visit. You say that you say that you have met your 
maximum out-of-pocket costs for the year. You say that you should not have to pay a copayment. The Plan 
denied your request. The Plan says you have been charged the correct copayment 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 $40 
copayment for each Medicare-covered out-of-network specialist visit.  
 
 
 You have been asked to pay a $40 copayment for an office visit. The office visit falls 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 an office visit provided on December 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
September 22, 2021, to September 30, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you had an allergic reaction to 
medication that caused you to stay longer. You say you should not have to pay for the stay. 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 $185 per 
day for days 1-7 and $0 per day for days 8-90 for each inpatient admission.  
 
The file shows that you were in the hospital from September 22, 2021, to September 30, 2021. Therefore, you 
have been asked to pay $185 per day for the first 7 days of inpatient care. The total for your stay is $1,295 ($185 copayment x 7 days = $1,295). The inpatient care 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 inpatient hospital care provided from 
September 22, 2021, to September 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
December 12, 2021, to December 24, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you cannot afford the 
copayment. 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 $185 per 
day for days 1-7 and $0 per day for days 8-90 for each inpatient admission.  
 
The file shows that you were in the hospital from December 12, 2021, to December 24, 2021. Therefore, you 
have been asked to pay $185 per day for the first 7 days of inpatient care. The total for your stay is $1,295 ($185 copayment x 7 days = $1,295). The inpatient care 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 inpatient hospital care provided from December 
12, 2021, to December 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a specialist office visit and X-rays of the 
shoulder provided on December 28, 2021. 
 
You asked the Plan to waive the copayments for the office visit and X-rays. You say that you were not aware 
of these copayments. 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 services obtained from a specialist. 
 
Your contract with the Plan also clearly says that you must pay a $15 copayment for each standard X-ray 
service. 
 
You have been asked to pay a $35 copayment for the office visit. The office visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. You have also been asked to 
pay a $15 copayment for the X-rays. The X-rays fall within the Outpatient Diagnostic Tests and Therapeutic 
Services and Supplies benefit category. The total for the visit is $50. 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 specialist office visit and X-rays of the shoulder provided on December 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a hospital outpatient clinic visit provided 
on February 1, 2022. 
 
You asked the Plan to waive the copayment for a hospital outpatient clinic visit. You say that you thought that 
laboratory work was covered.  You say that you don't believe you ever paid for laboratory services before. The 
Plan denied your request. The Plan says you have been charged the correct copayment 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 Medicare-covered surgery or other services provided to you at an ambulatory surgical center, 
including but not limited to hospital or other facility charges and physician or surgical charges.  You have been asked to pay $109.31, which is less than the standard $225 copayment for a hospital outpatient 
clinic visit. The hospital outpatient clinic visit 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 waive the copayment for a hospital outpatient clinic visit provided on February 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 5, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 an office visit provided on October 5, 2021 by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel 
to home or nursing home, set-up portable x-ray equipment, and an x-ray examination of the chest provided on 
November 4, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the transportation of portable x-ray equipment and personnel to home or nursing 
home, set-up portable x-ray equipment, and an x-ray examination of the chest. You say that the provider 
requesting this service is part of your network and should have requested authorization for these services and 
you should not be penalized for them neglecting to do so. The Plan denied your request. The Plan says the 
services are not authorized because this provider is a non-network provider who does not work with the Plan, and the member was referred by a provider who also does not work with the Plan. The Plan also says that the 
member's primary care physician did not refer for services. 
 
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 transportation of portable x-ray equipment and 
personnel to home or nursing home, set-up portable x-ray equipment, and an x-ray examination of the chest 
provided on November 4, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on December 28, 
2021. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you say that you have met your 
maximum out-of-pocket costs for the year. The Plan denied your request. The Plan says you have been charged 
the correct copayment 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 $40 
copayment for Medicare-covered out-of-network physical therapy visits.  
 
You have been asked to pay a $40 copayment for physical therapy. Physical therapy falls within the 
Outpatient rehabilitation 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 
physical therapy provided on December 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital debridement 
procedures provided on January 26, 2022, and February 9, 2022. 
 
You asked the Plan to waive the copayment for the outpatient hospital debridement procedures. You say that 
you cannot afford to pay the copayment. 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 $225 
copayment per visit for outpatient surgery or procedure.  
 
 
  You have been asked to pay a total of $450 ($225 copayment x 2 visits) for the outpatient hospital debridement 
procedures. The outpatient hospital debridement procedures 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 the outpatient hospital 
debridement procedures provided on January 26, 2022, and February 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for X-rays of the hand provided on February 
22, 2022. 
 
You asked the Plan to reduce the copayment for the X-rays. You say that you were advised that the copayment 
would only be $50. 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 X-rays are performed in an outpatient hospital facility.  
 
You have been asked to pay a $150 copayment for the X-rays. The X-rays fall 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 reduce the copayment 
for X-rays of the hand provided on February 22, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on December 
4, 2021. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that this charge should be 
covered. 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 $250 
copayment for each one-way Medicare-covered ground trip.  
 
 
 You have been asked to pay $250 copayment for ambulance transport. Ambulance transport 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 transport 
provided on December 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 9, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 an office visit provided on November 9, 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 dialysis services provided on January 1, 
2022 and February 1, 2022. 
 
You asked the Plan to waive the coinsurance for dialysis. You say that these charges are totally unreasonable 
and you do not want to pay them. The Plan denied your request. The Plan says the coinsurance amounts you 
are being charged are 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 outpatient renal dialysis services. The allowed amounts of these claims total $705.64, resulting 
in a total coinsurance amount of $141.12. 
 
You have been asked to pay 20% coinsurance for dialysis. Dialysis falls within the Services To Treat Kidney 
Disease 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 dialysis services provided 
on January 1, 2022 and February 1, 2022.  
 
The enrollees complaint about the experience with this provider is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that that no referral was needed for the office visit. You 
say authorization is not required for an in-network provider. The Plan denied your request. The Plan says no 
prior authorization was obtained. 
 
 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 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the office visit was urgent or emergent. Therefore, we decided that the Plan does 
not have to pay for the office visit provided on February 1, 2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral 
medications and had stable vital signs. The enrollee was at a modified independent to stand by assist level for 
functional mobility including gait to short distances. The enrollee does not require skilled nursing or therapy 
services on a daily basis. He does not meet severity of illness or intensity of service criteria for an inpatient 
basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory work provided on September 20, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory work. You say that you recently moved to this state and experienced 
an anxiety attack. You say that you needed to see the doctor to get help. The Plan denied your request. The 
Plan says no prior authorization was obtained. 
 
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 
laboratory work at issue. We found no exception that would require the Plan to pay for the laboratory work. 
The records provided for review do not show that the laboratory work was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for laboratory work provided on September 20, 2021, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology services provided on December 15, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for diagnostic radiology services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network 
and authorization is required prior to an out-of-network visit. 
 
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 diagnostic radiology services provided on 
December 15, 2021 by an out-of-network (OON) provider.