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

 
We decided that the Plan does not have to waive the coinsurance for a pembrolizumab (Keytruda) injection 
provided on July 12, 2021. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you changed insurance plans to 
cover these costs only a few weeks late. You say that you cannot afford the charges. 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 Part B chemotherapy drugs.  
 
You have been asked to pay $3,735.62, which is less than 20% of the allowed amount for the injection 
($18,779.51 allowed amount x 20% coinsurance = $3,755.90). The injection falls within the Medicare Part B Prescription Drugs benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a pembrolizumab 
(Keytruda) injection provided on July 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair (K0002). 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not have a significant mobility limitation. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 the wheelchair. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not support that the enrollee has a mobility deficit that impairs 
MRADLs in the home and that this mobility limitation is not sufficiently ameliorated by a walker or 
cane. While the enrollee may have the cognition to safely operate the manual wheelchair, the documentation 
does not reveal a home assessment to support that the requested device will be able to safely maneuver in the 
home and access rooms for MRADL participation. The documentation does not support that the manual 
wheelchair will  significantly improve the enrollee's ability to participate in MRADLs, and that the enrollee 
will use it in the home. The documentation does not reveal that the requested manual wheelchair is medically 
necessary 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a manual wheelchair (K0002).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the electrocardiogram (ECG) you had on 
October 18, 2021. 
 
You asked the Plan to waive the copayment for the ECG. You say that you had this service during the 
appointment for your annual physical, so the copayment should be waived. 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 $10 
copayment for outpatient diagnostic tests.   
You have been asked to pay a $10 copayment for the ECG. the ECG falls within the outpatient diagnostic tests 
benefit category. In addition, your Evidence of Coverage says that an annual physical includes the following 
services: bodily systems examinations, measurement and recording of vital signs, a complete medication 
review, and a review of any recent hospitalizations. An annual physical does not include diagnostic testing, so 
separate cost sharing can 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 copayment for the electrocardiogram 
(ECG) you had on October 18, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on 
September 24, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that when you went to the ER, you had to 
wait under a tent and all you had done was a temperature check.  You do not think you should be responsible 
for this copayment. 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 $75 
copayment for emergency room visits.  
 
You have been asked to pay a $75 copayment for the ER visit. This copayment applies each time you visit the 
ER, regardless of the extent of services you receive. 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 emergency room (ER) visit you had on September 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-rays provided on November 12, 2021. 
 
You asked the Plan to waive the copayment for the x-rays. You say that the services should be covered as the 
charges are incorrect. 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 $20 
copayment for each Outpatient diagnostic test and therapeutic services and supplies.  
 
 
 You have been asked to pay a $40 copayment for two x-rays. The record indicates that you received two 
separate x-rays performed by two different providers. 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 waive the copayment for x-
rays provided on November 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a computed tomographic angiography 
(CT) scan.provided on October 12, 2021. 
 
You asked the Plan to waive the coinsurance for the computed tomographic angiography (CT) scan. You say 
that the services should be covered in full and you shouldn't have to pay. The Plan denied your request. The 
Plan says the coinsurance 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 20% 
coinsurance for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 You have been asked to pay a 20% coinsurance for a computed tomographic angiography (CT) scan (allowed 
is $344.66 x 20% = $68.93) Computed tomographic angiography (CT) scans 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 waive the 
coinsurance for a computed tomographic angiography (CT) scan.provided on October 12, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 testing provided on March 30, 2021. 
 
You asked the Plan to pay for COVID-19 testing. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 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 COVID-19 testing provided on March 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for psychotherapy visits provided from 
September 29, 2021, to November 3, 2021. 
 
You asked the Plan to waive the copayment for the psychotherapy visits. You say that the services should be 
covered at a higher rate because you had the same services provided by a different provider and it was cheaper. 
The Plan denied your request. The Plan says the coat-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 $18 
copayment for Outpatient mental health care.  
 
 
 You have been asked to pay a $90 copayment for 5 psychotherapy visits. Psychotherapy visits fall within the 
Outpatient mental health care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
psychotherapy visits provided from September 29, 2021, to November 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist office visits provided on August 
9, 2021, and August 24, 2021. 
 
You asked the Plan to waive the copayments for the specialist office visits. You say that the provider informed 
you that your copayments would only be $20. 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 each specialist visit.  
 
You have been asked to pay a $50 copayment for each of the specialist office visits. The specialist office visits 
fall within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayments for specialist office visits provided on August 9, 2021, and August 24, 
2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on 
September 27, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you do not feel as though you should 
have to pay this copayment.  You said you went to the ER and were triaged by a nurse.  You also had blood 
work and you provided a urine sample.  You said that you then waited 5 hours before being seen, so you left. 
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 $75 
copayment for emergency room visits.  
 
You have been asked to pay a $75 copayment for the ER visit. This copayment applies each time you visit the 
ER, regardless of the extent of services you receive. 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 emergency room (ER) visit you had on September 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services you received on October 13, 
2021. 
 
You asked the Plan to waive the copayment for the lab services. You say that this copayment should be waived 
because these labs were drawn prior to seeing the doctor on the same day. The Plan denied your request. The 
Plan says you did not have a copayment for the office visit you had on that date, so the copayment for the lab 
services was charged 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 $10 
copayment for lab services.  
 
 
 You have been asked to pay a $10 copayment for the lab services. You are correct that you had an office visit 
on the same day as this lab service.  However, according to your contract, the lab copayment does not apply if 
you visit your doctor on the same date of service that the lab service was performed, and your plan has an 
office copayment for that visit. There was no copayment for the office visit you had.  In this scenario, there is 
no waiver of the lab copayment. 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 lab services you received 
on October 13, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you need to continue care at the facility. The 
Plan denied your request. The Plan says that you no longer require skilled services and the continuation of SNF 
is not medically necessary. 
 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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for continued SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital clinic visit you had 
on October 26, 2021. 
 
You asked the Plan to waive the copayment for the outpatient hospital clinic visit. You say that you feel as 
though this is a ridiculous charge to talk to a doctor for five minutes.  You don't think you should have to pay a 
charge to the facility. The Plan denied your request. The Plan says you were charged this copayment correctly.  
The Plan says that because the allowed amount for this service ($128.35) is less than your copayment 
obligation, you are responsible for the full allowed 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 $395 
copayment for non-surgical visits wot an outpatient clinic.  
 
You have been asked to pay a $395 copayment for the outpatient hospital clinic visit. 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 clinic visit you had on October 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on 
December 17, 2021. 
 
You asked the Plan to waive the copayment for the specialist telehealth visit. You say that you feel that you 
should not be responsible for the copayment since you did not know this doctor and they did not help. 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 $30 
copayment for each specialist telehealth visit.  
 
You have been asked to pay a $30 copayment for the specialist telehealth visit. The specialist telehealth 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 a specialist telehealth visit provided on December 17, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
September 19, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you had no choice but to go to the 
ER since urgent care was closed and the surgeon did not return your calls. 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 $120 
copayment for each emergency room visit. 
 
You have been asked to pay a $120 copayment for the ER visit. The ER visit falls within the Emergency Care 
benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for an emergency room (ER) visit 
provided on September 19, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services you received 
from October 25, 2021, to December 6, 2021. 
 
You asked the Plan to waive the copayment for the PT services. You say that the provider never told you that 
there would be a $25 charge per visit and they never collected it during your visits. The Plan denied your 
request. The Plan says you were charged these copayments 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 $25 
copayment per visit for physical therapy services.  
 
 You have been asked to pay a $25 copayment per visit for the PT services. Your Evidence of Coverage clearly 
states that this is a per-visit charge. 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 
(PT) services you received from October 25, 2021, to December 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the computed tomography (CT) scan of 
the chest you had on October 22, 2021. 
 
You asked the Plan to waive the coinsurance for the CT scan. You say that you should not have to pay anything 
for this service. 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 20% 
coinsurance up to $75 per day for diagnostic radiology services.  
 
You have been asked to pay 20% coinsurance for the CT scan. The CT scan 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 coinsurance for the computed 
tomography (CT) scan of the chest you had on October 22, 2021.