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

 
We decided that the Plan does not have to waive the copayment for out-of-network x-ray provided on May 03, 
2022. 
 
You asked the Plan to waive the copayment for out-of-network x-ray. You say that this would have been a $0 
copayment but your provider did not have the correct equipment, which is why they sent you to a different 
facility. The Plan denied your request. The Plan says this cost sharing 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 $50 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $50 copayment for out-of-network x-ray. This item/service 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 out-of-network x-ray provided on May 03, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the wrist x-rays provided on July 27, 2022. 
 
You asked the Plan to waive the copayment for the wrist x-rays. You say that the x-rays should be covered in 
full. The Plan denied your request. The Plan says this cost sharing 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 $77.58 
copayment for basic radiological services at an outpatient hospital. 
 
You have been asked to pay a $77.58 copayment for the wrist x-rays. This item/service falls within the basic 
radiological services at an outpatient hospital 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. The allowed amount for the x-rays is $77.58. Since this is less than the $100 
copayment per the EOC, you are only responsible for the lesser amount. Therefore, we decided that the Plan 
does not have to waive the copayment for the wrist x-rays provided on July 27, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on October 
21, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you were told you would not 
be responsible for a copayment if you were admitted to the hospital The Plan denied your request. The Plan 
says this cost sharing 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 $300 
copayment for ambulance services. 
 
You have been asked to pay a $300 copayment for ambulance services. This item/service 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 services 
provided on October 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic on February 01, 2022. 
 
You asked the Plan to waive the copayment for outpatient diagnostic. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says this cost sharing 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 $150 
copayment for diagnostic procedures and tests at outpatient hospital. Covered services included but are not 
limited to laboratory and diagnostic tests billed by the hospital. The provider billed in the amount of $632 and 
the Plan discounts is $472.73. $632 - $472.73 = $159.27. The Plan paid $14. $159.27 - $14 = $145.27. This is 
less than the copayment amount. Therefore, results in the total cost sharing amount of $145.27. 
 
 
 
 
 You have been asked to pay a $145.27 copayment, which is less than the copayment for outpatient diagnostic. 
This item/service 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 outpatient diagnostic on February 01, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on November 03, 
2021, to November 09, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says this cost sharing 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 $320 
copayment per day for days 1-5 $0 copayment per day for days 6 and beyond. There is a $1,600 out-of-pocket 
limit per stay. Includes inpatient acute, inpatient rehabilitation, long-term care hospitals and other types of 
inpatient hospital services. Inpatient hospital care starts the day you are formally admitted to the hospital with a 
doctors order. The day before you are discharged is your last inpatient day. $320 x 5 = $1,600. Therefore, 
results in the total cost sharing amount of $1,600. 
 
 
 You have been asked to pay a $320 copayment per dayfor inpatient hospital stay. This item/service 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 stay on November 03, 2021, to November 09, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient rehab provided on February 
16, 2022, to March 10, 2022. 
 
You asked the Plan to waive the copayment for the inpatient rehab. You say that you were not aware that 
transferring to rehab was a new admission. The Plan denied your request. The Plan says this cost sharing 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 $1,500 
copayment for inpatient hospital care. 
 
You have been asked to pay a $1,500 copayment for the inpatient rehab. This item/service 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. The file shows that you were transferred to rehabilitation care from February 16, 2022, to 
March 10, 2022. This transfer is considered a new admission. The EOC says there is a $300 copayment per day 
for days 1-5 of each inpatient admission. Therefore, theTherefore, we decided that the Plan does not have to 
waive the copayment for the inpatient rehab provided on February 16, 2022, to March 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of 
the brain provided on May 26, 2022. 
 
You asked the Plan to waive the copayment for the MRI. You say that you went to their medical clinic and not 
a hospital. 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 $100 
copayment for advanced imaging services at an outpatient hospital.  
 
You have been asked to pay a $100 copayment for the MRI. The MRI falls within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for the magnetic resonance imaging (MRI) of the brain provided on May 26, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care on April 
09, 2022, to May 09, 2022. 
 
You asked the Plan to waive the copayment for skilled nursing facility (SNF) care. You say that the enrollee 
wants to appeal the amount being charged. The Plan denied your request. The Plan says the cost sharing the 
enrollee is being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 
copayment for days 120. $100 copayment per day for days 21100. The Plan covers up to 100 days per 
benefit period of skilled inpatient services in a skilled nursing facility in accord with Medicare guidelines (a 
prior hospital stay is not required). Between April 29, 2022, and May 09, 2022, there is a $100 copayment each 
day. There were 10 days. $100 x 10 = $1,000. Therefore, results in the total cost sharing amount of $1,000.   
 
 
 
 You have been asked to pay a $100 copayment per day for skilled nursing facility (SNF) care. Skilled nursing 
facility (SNF) care falls within the Skilled nursing facility (SNF) 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 skilled nursing facility (SNF) care on April 09, 2022, to May 09, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee on October 26, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the physician signature is illegible. 
 
The Plan must follow Medicare rules. Medicare rules say that home health services must be reported properly. 
 
The physician signature on the plan of care is illegible. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for home health services provided to the enrollee on October 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 22, 2022 billed with 
codes 81201, 81317, 81404, 81405, 81406, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this should be paid for. The Plan denied 
your request. The Plan says a panel constitutes a single procedural service, so one code must be submitted. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 22, 2022 billed with codes 81201, 81317, 81404, 81405, 81406, and 81479.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, a motion fluoroscopy/swallow, an x-ray 
examination of the esophagus, an x-ray examination of the neck and spine, an x-ray examination of the jaw, an 
x-ray examination of the teeth, and an x-ray examination of the upper gastrointestinal tract provided on April 
29, 2022, by an out-of-network (OON) provider. 
 You asked the Plan to pay for an office visit, a motion fluoroscopy/swallow, an x-ray examination of the 
esophagus, an x-ray examination of the neck and spine, an x-ray examination of the jaw, an x-ray examination 
of the teeth, and an x-ray examination of the upper gastrointestinal tract. You say that the member required 
these services due to medical necessity. The Plan denied your request. The Plan says a non-contracted provider 
performed these services to the member without prior authorization from the Plan. 
 
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, a motion fluoroscopy/swallow, an 
x-ray examination of the esophagus, an x-ray examination of the neck and spine, an x-ray examination of the 
jaw, an x-ray examination of the teeth, and an x-ray examination of the upper gastrointestinal tract provided on 
April 29, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device insertion. 
 
You asked the Plan to pre-approve the Vertiflex device insertion. You say that you need this procedure for your 
back pain. You say that the procedure is medically necessary and covered by Medicare. The Plan denied your 
request. The Plan says Medicare does not cover unproven and not medically necessary procedures. 
 
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 Vertiflex device insertion. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that there is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. 
 
  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 Vertiflex device insertion have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Vertiflex device insertion.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient surgery and x-rays provided on 
October 20, 2021, and October 29, 2021. 
 
You asked the Plan to waive the copayments for outpatient surgery and x-rays. You say that these services 
should be covered. The Plan denied your request. The Plan says the copayments applied 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 $25 
copayment for x-rays and $275 for outpatient surgery. 
.   
You have been asked to pay $300 copayment for outpatient surgery and x-rays. X-rays falls within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. Outpatient 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 copayments for outpatient surgery 
and x-rays provided on October 20, 2021, and October 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on 
December 10, 2021. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that these services should be 
covered. The Plan denied your request. The Plan says this cost sharing 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 $25 
copayment for Visits to your Specialists. 
 
You have been asked to pay a $25 copayment for specialist office visit. This item/service falls within the Visits 
to your Specialists 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 specialist office visit 
provided on December 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the radiologic examination (X-ray) of the 
neck provided on May 6, 2022. 
 
You asked the Plan to waive the copayment for the X-ray. You say that if you had known you could of went 
somewhere else to get a $35 copayment you would have. 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 $100 
copayment for diagnostic procedures and tests in an outpatient hospital.  
 
You have been asked to pay a $100 copayment for the X-ray. The X-ray 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 radiologic examination 
(X-ray) of the neck provided on May 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair batteries, labor, and sales tax (E2361, K0739, 
and S9999) provided on March 18, 2022. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the supplier is not enrolled in 
the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the wheelchair batteries, labor, and sales 
tax (E2361, K0739, and S9999) provided on March 18, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound on May 18, 2022. 
 
You asked the Plan to waive the copayment for ultrasound. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110 
copayment for Medicare-covered radiological diagnostic services, not including X-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic). Covered services 
include but are not limited to other outpatient diagnostic tests - Radiological diagnostic services, not including 
x-rays. The provider billed in the amount of $168 and the allowed amount is $69.35. This is less than the 
copayment amount. Therefore, results in the total cost sharing amount of $69.35. 
 
 
 You have been asked to pay a $69.35 copayment, which is less than the copayment for ultrasound. Ultrasound 
falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for ultrasound on May 18, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the abdominal ultrasound provided on 
June 08, 2022. 
 
You asked the Plan to reduce the copayment for the abdominal ultrasound. You say that insurance should pay 
more on this claim. The Plan denied your request. The Plan says this cost sharing 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 $100 
copayment for diagnostic procedures and tests at an outpatient hospital. 
 
You have been asked to pay a $100 copayment for the abdominal ultrasound. This item/service falls within the 
diagnostic procedures and tests at an outpatient hospital 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 the abdominal ultrasound provided on June 08, 2022.