Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Lyme disease test provided on May 25, 2021.
You asked the Plan to waive the copayment for the Lyme disease test. You say that you did not go to this provider. 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 $10 copayment
for each lab test.
You have been asked to pay a $10 copayment for the Lyme disease test. The record shows the lab sample was sent to this
provider for analysis. The Lyme disease test 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 Lyme disease test provided on May 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for inpatient hospital services you received
from July 28, 2021, to July 30, 2021, and July 30, 2021, to August 23, 2021.
You asked the Plan to waive the copayments for the two inpatient hospital admissions. You say that you were
charged two copayments for the same hospital. The Plan denied your request. The Plan says you were charged
two admission copayments correctly. The Plan says that you were in an acute inpatient admission from July
28, 2021, to July 30, 2021. You were discharged from acute care and were then admitted to inpatient
rehabilitation from July 30, 2021, to August 23, 2021. Since these were separate admissions at different levels
of care, two separate copayments apply.
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 admission for inpatient hospital services.
You have been asked to pay a $325 copayment per admission for the acute inpatient admission and the
inpatient rehabilitation admission. Your Evidence of Coverage explicitly states that if you are discharged from
one level of care and readmitted to another level of care, separate copayments will 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 copayments for inpatient hospital services you received from July 28, 2021, to July
30, 2021, and July 30, 2021, to August 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgent care services provided on August 1,
2021.
You asked the Plan to waive the copayment for the urgent care services. You say that you cannot afford this
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 a $50
copayment for urgently needed services provided in an urgent care center.
You have been asked to pay a $50 copayment for the urgent care services. Urgent care services fall 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 urgent care
services provided on August 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for chiropractic
services.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no gap issue, and there are in-network providers available.
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 referral to an out-of-network provider for chiropractic services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for radiology services you received on July 15,
2021.
You asked the Plan to waive the deductible for the radiology services. You say that you believe you met your
deductible in July, so you should only have a copayment. The Plan denied your request. The Plan says you had
not met your deductible prior to these services. There was $549.35 remaining on your deductible as of July 15,
2021.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $750 deductible which applies to radiology services.
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which
applies to radiology services. This cost sharing is a contractual obligation that had not been met at the time the
radiology services was received on July 15, 2021. Therefore, we decided that the Plan does not have to waive
the deductible for radiology services you received on July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement (97597) provided on March 11, 2021.
You asked the Plan to pay for the debridement. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says the documentation submitted does not support
the service billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the
Plan was correct in denying the request to pay for the debridement. Our reviewer says that CPT code 97597
does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records
provided does not include sufficient documentation to validate that a Debridement (eg, high pressure waterjet
with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin,
devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound
assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s)
surface area; first 20 sq cm or less was performed on March 11, 2021, therefore this service cannot be verified.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the debridement have not been met. Therefore, we decided that the Plan does
not have to pay for the debridement (97597) provided on March 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) you
had on August 11, 2021.
You asked the Plan to waive the copayment for the MRI. You say that this procedure was 'okayed' by your
plan. You said that you were never told about any copayments, or you would not have had the procedure. The
Plan denied your request. The Plan says you were charged this copayment 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 $275
copayment for diagnostic radiology services.
You have been asked to pay a $275 copayment for the MRI. The MRI falls within the diagnostic radiology
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 magnetic resonance
imaging (MRI) you had on August 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received
from April 16, 2021, to April 22, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you had a bad fall
and were admitted to the hospital from April 11, 2021, to April 15, 2021. You said you were transported to the
hospital's West facility for further treatment. You don't believe you should have a copayment for the continued
stay. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says
that you were in an acute care hospital from April 11, 2021, to April 15, 2021. You were discharged from the
acute care hospital and then admitted to an inpatient rehabilitation facility where your stay lasted from April
16, 2021, to April 22, 2021. These are two separate admissions at two separate facilities, so the copayments
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 a $395
copayment per day for days 1-4, and $0 for additional days for inpatient hospital services.
Your Evidence of Coverage explicitly states that a transfer to a separate facility type (such as inpatient
rehabilitation) is considered a new admission. That was the case here. You were in the inpatient rehabilitation
hospital for 6 days. You were charged a $395 copayment per day for each of the first four days, for a total of
$1580. 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 services you received from
April 16, 2021, to April 22, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transport provided on April 8, 2021.
You asked the Plan to pay for the ambulance transport. The Plan denied your request. The Plan says Original
Medicare is responsible for payment.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the ambulance transport provided on April 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Ambulance transportation services (A0425,
A0428, A0429) provided on December 12, 2020, and December 15, 2020.
You asked the Plan to waive the copayment for Ambulance transportation. You say that the services should be
covered as they were related to your covid-19 diagnosis. The Plan denied your request. The Plan says the cost-
sharing applied correctly based on the services 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 a $250
copayment for Ambulance services.
You have been asked to pay a $250 copayment for Ambulance transportation provided on December 12, 2021,
and a $183.26 copayment for Ambulance transportation provided on December 15, 2021, which is less than the
$250 stated in the Plan's contract for a total of $433.26. There are no guidelines for waiving ambulance
transportation services due to covid related issues. 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 (A0425, A0428, A0429) provided on December 12, 2020, and December
15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 13, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on January 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received
from July 22, 2021, to July 25, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were kept in
the emergency room on the first day. The Plan denied your request. The Plan says you were charged this
copayment correctly. The Plan says that the medical records show you were admitted as an inpatient through
the emergency room on July 22, 2021.
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 per day for days 1-3 for inpatient hospital services.
Records show that you were admitted on July 22, 2021, and discharged on July 15, 2021. You were charged a
$250 copayment per day for a total of $750.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 services you received from July 22, 2021, to July 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for office visits (99204, 99213) provided on
August 2, 2021, and August 23, 2021.
You asked the Plan to waive the copayment for office visit. You say that the services should be covered as the
office visits were rendered due to the aftereffects of having covid-19. The Plan denied your request. The Plan
says the cost-sharing applied correctly based on the services 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 a $40
copayment for Physician/Practitioner services, including doctor's office visits.
You have been asked to pay a $40 copayment for an office visit provided on August 2, 2021, and a $40
copayment for an office visit provided on August 23, 2021, for a total of $80. There are no guidelines from the
Plan that state services provided due to the aftereffects of having covid-19 would be waived. 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 office visits (99204, 99213) provided on August 2, 2021, and August
23, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost sharing for the visit you had with an out-of-network
endocrinologist on August 12, 2021.
You asked the Plan to reduce the cost sharing for the out-of-network endocrinology visit. You say that this
provider is in-network, so you should only have a $40 copayment. The Plan denied your request. The Plan says
you were charged this coinsurance 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 40%
coinsurance for out-of-network physician services.
You have been asked to pay 40% coinsurance for the out-of-network endocrinology visit. We confirmed in the
Plan's online provider directory that the endocrinologist you saw on this date is not a network provider with
your specific plan. 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 cost sharing for the visit you had with an out-
of-network endocrinologist on August 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 5, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in a nursing facility setting and
should have been billed with POS code 32. Therefore, we decided that the Plan does not have to pay for the
laboratory services rendered on August 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for back surgery performed from July 22,
2021, to July 29, 2021.
You asked the Plan to waive the coinsurance for the back surgery. You say that you were admitted to the
hospital after surgery, and you should not be responsible for the outpatient cost share. The Plan denied your
request. The Plan says the correct coinsurance 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 20%
coinsurance for surgery performed at an outpatient hospital facility.
Procedure Allowed Amount 20% Coinsurance
Lab - July 27, 2021 $8.10 $1.62
Lab - July 29, 2021 $8.10 $1.62
Lab - July 26, 2021 $4.05 $0.81
Lab - July 27, 2021 $4.05 $0.81
Lab - July 28, 2021 $4.05 $0.81
Operating Room - July 26, 2021 $17777.23 $3555.45
Physical Therapy - July 27, 2021 $102.81 $20.56
Occupational Therapy - July 27, 2021 $78.86 $15.77
Total: $3597.45
You have been asked to pay $3597.45, which is 20% of the allowed amount for the back surgery. The record
shows that you were not admitted as an inpatient. Back surgery falls within the Outpatient Surgery, Including
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 coinsurance for back surgery performed from July 22, 2021, to July 29,
2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the computed tomography (CT) scan and
the positron emission tomography (PET) scan you had on August 5, 2021.
You asked the Plan to waive the copayments for the CT scan and the PET scan. You say that you only had a
PET scan, not a CT scan on this date. You said that you should not have to pay both copayments. The Plan
denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325
copayment each for CT scans and PET scans.
You have been asked to pay a $325 copayment each for the CT scan and the PET scan. We looked at the
medical records to determine what services you received. The records clearly show that you received both a
CT scan and a PET scan on this date. 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 computed
tomography (CT) scan and the positron emission tomography (PET) scan you had on August 5, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit, X-Rays, and chiropractic manipulative
treatment provided on August 26, 2021.
You asked the Plan to pay for office visit, X-Rays, and chiropractic manipulative treatment. You say that your
provider is performing manual manipulation of the spine to correct subluxation. The Plan denied your request.
The Plan says the denial of payment for these services is correct, because an office visit and X-Rays are not
covered by Medicare or the Plan when performed by a chiropractor. The Plan also says that you must pay $20
copayment for the covered chiropractic manipulative treatment.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation. The rules say a plan must disclose to its enrollees in
clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your
contract with the Plan clearly says that you must pay $20 copayment for each covered chiropractic visit.
The records show that the office visit and X-Rays at issue are not manual manipulation of the spine; therefore,
they are not covered by Medicare or the Plan when performed by a chiropractor. You have also been asked to
pay $20 copayment for the covered chiropractic manipulative treatment. This copayment is a contractual
obligation you agreed to when you enrolled in the Plan. Therefore, we decided that the Plan does not have to
pay for an office visit, X-Rays, and chiropractic manipulative treatment provided on August 26, 2021.