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

 
We decided that the Plan does not have to reduce the coinsurance for a negative pressure wound therapy pump 
provided from February 8, 2022, to February 28,2022, and on March 1, 2022.  
 
You asked the Plan to reduce the coinsurance for a wound therapy pump. You say that you do not feel that you 
should be responsible for the cost of the rental because it is so high. You also say that you expected to be 
responsible for some of the rental, but the $628 bill is too high. 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 20% 
coinsurance for in-network durable medical equipment.  
 
 The record shows these claims were approved, and you have a cost sharing amount. You have been asked to 
pay $600.60, which is 20% coinsurance of the allowed amount for a wound therapy pump provided from 
February 8, 2022, to February 28, 2022 ($3,003 allowed amount x 20% coinsurance = $600.60). You have also 
been asked to pay $28.60, which is 20% coinsurance of the allowed amount for a wound therapy pump 
provided on March 1, 2022 ($143 allowed amount x 20% coinsurance = $28.60). You have been asked to pay a 
total of $629.20 ($600.60 coinsurance + $28.60 coinsurance = $629.20). A wound therapy pump falls within 
the Durable Medical Equipment (DME) and Related Supplies benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to reduce the coinsurance for a negative pressure wound therapy pump provided from February 8, 2022, to 
February 28,2022, and on March 1, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy with polyp 
removal provided on February 25, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you have had five other 
colonoscopies with polyps removed and never been charged a $200 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 $200 copayment for outpatient surgery at an 
ambulatory surgical center. The Plans contract also says that when a screening colonoscopy or sigmoidoscopy 
becomes a diagnostic procedure (e.g., results in a biopsy or removal of a lesion or growth), then outpatient 
surgery cost sharing may apply. 
 
The medical record shows you had a diagnostic colonoscopy with polyps removed on February 25, 2022. 
Therefore, a cost sharing amount applies. You have been asked to pay a $200 copayment for a diagnostic 
colonoscopy. A diagnostic colonoscopy 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 copayment for a diagnostic colonoscopy with polyp removal provided on February 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an aspiration biopsy provided on 
November 4, 2021. 
 
You asked the Plan to waive the copayment for an aspiration biopsy. You say that the biopsy was done purely 
for a diagnostic purpose and in no way should be considered as a surgical service. 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 $325 
copayment for surgical service at an in-network outpatient hospital facility.  
 
 
 You have been asked to pay a $325 copayment for an aspiration biopsy. The aspiration biopsy 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 copayment for an aspiration biopsy 
provided on November 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible an office visit provided on December 23, 2021. 
 
You asked the Plan to waive the deductible the office visit. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says the deductible 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. Your 
contract with the Plan says that there is a $203 deductible which applies to Physician/Practitioner services, 
including doctor's office visits.  
 
 
  The item or service you asked the Plan to waive the deductible falls within the benefit category 
Physician/Practitioner services, including doctor's office visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $203 deductible which applies to Physician/Practitioner 
services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at 
the time the office visit was received on December 23, 2021. Therefore, we decided that the Plan does not have 
to waive the deductible an office visit provided on December 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the lumbar spine without contrast. 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that an MRI of the lumbar spine is 
medically necessary. The Plan denied your request. The Plan says an MRI of the lumbar spine is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 an MRI of the lumbar spine. Our 
reviewer says that an MRI of the lumbar spine is not medically necessary. Our physician reviewer found that 
you have Type 2 Diabetes and no plain lumbar spine films are in the records. In addition, there is no history of 
trauma or sign of infection. There is no known malignancy. A neurological exam shows no red flag such as 
absent reflex, etc. There is no history of conservative management including physical therapy (PT). Without a 
red flag, the medical necessity of an MRI without a trial of PT has not been established in the records provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the lumbar spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an MRI of the lumbar spine without contrast.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office evaluation provided on December 10, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON office visit. You say that this was medically necessary. The Plan denied 
your request. The Plan says this was provided OON without authorization. There is no evidence this was an 
emergency visit or that network providers were not 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 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 office evaluation provided on December 10, 
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 deductible for outpatient hospital services provided on 
February 9, 2022. 
 
You asked the Plan to waive the deductible for the outpatient hospital services. You say that the services should 
be covered as you disagree with the charges. 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. Your 
contract with the Plan says that there is a $750 deductible which applies to Outpatient hospital observation.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
hospital observation. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$750 deductible which applies to Outpatient hospital observation. This cost sharing is a contractual obligation 
that had not been met at the time the outpatient hospital services was received on February 9, 2022. Therefore, 
we decided that the Plan does not have to waive the deductible for outpatient hospital services provided on 
February 9, 2022.  
 
Since the deductible was met, you have also been asked to pay a $3,819.89 coinsurance for the outpatient 
hospital services. 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 outpatient hospital services 
provided on February 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on December 
9, 2021. 
  You asked the Plan to pay for the special anesthesia service (99100). You say that this is payable per CMS 
guidelines and the attached records should be reviewed. You say that the claim should be processed for 
payment at $355.55 per the contract. The Plan denied your request. The Plan says bundled services are not 
eligible for separate reimbursement. 
 
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 find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the special anesthesia service (99100) have not been met. Therefore, we decided that the Plan does not have 
to pay for the special anesthesia service (99100) provided on December 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan. 
 
You asked the Plan to pre-approve a PET scan. You say that a PET scan is medically necessary. The Plan 
denied your request. The Plan says the PET scan does not meet the Medicare NCD coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
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 a PET scan. Our reviewer says that a 
PET scan is not medically necessary. Our physician reviewer found the presence of left upper lobe atelectasis 
and bronchiectasis in a patient with recent COVID-19 infection is not a valid reason for PET/CT. In particular 
there has been no follow-up CT after appropriate treatment to determine if chronic atelectasis is a problem. 
Likewise, no bronchoscopy has occurred. PET/CT is indicated for analysis of a solid pulmonary nodule over  
1 centimeter in diameter or when there is abnormal sputum cytology suspicious for cancer. Medical necessity 
for PET/CT has not been demonstrated in the records provided. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for a specialist office visit (99215) and an 
aprepitant injection (J0185) provided on January 18, 2022, and March 1, 2022. 
 
You asked the Plan to waive the cost-sharing for the specialist office visit and aprepitant injection. You say that 
the services should be covered as you disagree with the charges. 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 $45 
copayment for Physician/Practitioner services, including doctors office visits, specifically specialist visits and 
a 20% coinsurance for Medicare Part B prescription drugs and the administration of them. You have been asked to pay a $45 copayment for the specialist office visit and a 20% coinsurance for the 
aprepitant injection (allowed is $223.60 x 20% = $44.72). 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-sharing 
for a specialist office visit (99215) and an aprepitant injection (J0185) provided on January 18, 2022, and 
March 1, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
September 24, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you are disputing 
the charge for services that were not performed. 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 $225 
copayment for each one-way ambulance trip.  
 
The record shows that you were transported to the hospital on September 24, 2021. Therefore, you have been 
asked to pay a $225 copayment for the ambulance transportation. The ambulance transportation falls within the Ambulance Services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance 
transportation provided on September 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for General Health Panel provided on December 27, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for General Health Panel. You say that you would like to appeal the denial of the 
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 General Health Panel provided on December 27, 
2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
February 5, 2021, to February 11, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the services should be 
covered as you disagree with the charges. 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 $360 
copayment per day for days 1 to 5 of Inpatient hospital care.  
 
 
  You have been asked to pay a $1,800 copayment for 5 days of inpatient hospital care ($360 x 5 = $1,800). This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an inpatient hospital stay provided from February 5, 2021, 
to February 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the extremity brace provided on December 
28, 2021. 
 
You asked the Plan to waive the coinsurance for the extremity brace. You say that you shouldn't have to pay 
because it was uncomfortable and bruised your hand. The Plan denied your request. The Plan says the 
coinsurance 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 10% 
coinsurance for covered items and related supplies.  
 
 
  You have been asked to pay $43.09 (allowed amount= $430.87 x 10%) for the extremity brace. The extremity 
brace falls within the Durable medical equipment (DME) and related supplies benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for the wrist hand orthosis (extremity brace) provided on December 28, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fundus photography with interpretation and report 
(92250), the office visit (99214), and the scanning computerized ophthalmic diagnostic imaging, posterior 
segment, with interpretation and report, unilateral or bilateral; of the retina (92134) rendered by the out-of-
network (OON) provider on October 27, 2021. 
 
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 fundus photography with interpretation and report (92250), the office visit 
(99214), and the scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation 
and report, unilateral or bilateral; of the retina (92134) rendered by the out-of-network (OON) provider on 
October 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Telemedicine Evaluation provided on March 21, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Telemedicine Evaluation. You say that you would like to appeal the denial of the 
claim. The Plan denied your request. The Plan says the provider is out-of-network and it was determined these 
services 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 Telemedicine Evaluation provided on March 21, 
2022 by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive your $120 copayment for emergency services provided on 
July 25, 2021. 
 
You asked the Plan to waive your $120 copayment for emergency services. You say that you should not be 
responsible for your copayment. The Plan denied your request. The Plan says you must pay a $120 copayment 
for Emergency Room services. 
 
 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 $120 
copayment for Emergency Care.  
 
You have been asked to pay a $120 copayment for emergency services. Emergency services fall 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 your $120 copayment for emergency 
services provided on July 25, 2021.