Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided from May 
30, 2022, to June 2, 2022, and an office visit provided on June 8, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay and an office visit. You say that you 
shouldn't have to pay for this since this is from a surgery that went wrong. 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 $600 
copayment for each Medicare covered hospital stay and a $40 copayment for a visit to a specialist.  
 
 You have been asked to pay a total of $640 copayment for inpatient hospital stay and an office visit. This 
item/service falls within the Inpatient Hospital Care and Physician/Practitioner Services, Including Doctors 
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 inpatient hospital stay 
provided from May 30, 2022, to June 2, 2022, and an office visit provided on June 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the medical eye provided on May 31, 
2022. 
 
You asked the Plan to reduce the copayment for the medical eye exam. You say that your cataracts are being 
monitored by your doctor. You say you have a $10 copayment. 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 $20 
copayment for each Medicare-covered exam to diagnose and treat diseases or conditions of the eye.  
 
 
 
 
 
 You have been asked to pay a $20 copayment for the medical eye exam. This item/service falls within the 
vision 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 reduce the copayment for the medical eye provided 
on May 31, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for an emergency department visit provided on December 5, 2021. 
 
You asked the Plan to pay for the emergency department visit. You say that the services were rendered in an 
emergent circumstance. The Plan denied your request. The Plan says that per CMS article A52978, the 
diagnosis code billed, K04.7, is a routine service diagnosis, which is not covered by Medicare, or this Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided us with a rule to support an emergency 
department visit for a non-routine dental service. Therefore, we decided that the Plan has to pay for an 
emergency department visit provided on December 5, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for colonoscopy on June 02, 2022. 
 
You asked the Plan to waive the copayment for colonoscopy. 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 $200 
copayment for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital 
facility. Covered services include, but are not limited to services in an emergency department or outpatient 
clinic, such as observation services or outpatient surgery. 
 
You have been asked to pay a $200 copayment for colonoscopy. 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 colonoscopy on June 
02, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room visit provided on July 10, 
2022. 
 
You asked the Plan to waive the copayment for emergency room visit. You say that you should not have to pay 
for the emergency room visit 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 $90 
copayment for Emergency care. 
 
You have been asked to pay a $90 copayment for emergency room visit. This item/service 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 emergency room 
visit provided on July 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assessment of and care planning services provided on 
May 4, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the assessment of and care planning services. You say that the service provided 
was medically necessary to treat the enrollee and you would like the claim paid. The Plan denied your request. 
The Plan says the rendering provider is an OON provider and there was no approved authorization. Also, the 
service rendered was 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 the assessment of and care planning services 
provided on May 4, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a lesion removal procedure provided on 
June 7, 2022. 
 
You asked the Plan to waive the copayment for a lesion removal procedure. You say that you feel you are 
getting charged for being a healthy person having a screening done. 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 $125 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You are being asked to pay a $100 copayment, rather than the full copayment of $125 for a lesion removal 
procedure. This item/service 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 lesion removal procedure provided on June 7, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services provided on November 10, 2021, to 
November 27, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for therapy services. You say that there was an error made by one of your therapy 
reps. The Plan denied your request. The Plan says the requested services are not covered 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 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 therapy services provided on November 10, 2021, 
to November 27, 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 copayment for hospital outpatient services on April 13, 
2022. 
 
You asked the Plan to waive the copayment for hospital outpatient services. You say that you would like to 
appeal the cost share. 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 $250 
copayment for each Medicare-covered visit to an Outpatient hospital facility for hospital outpatient services.  
 
You have been asked to pay a $250 copayment for each Medicare-covered visit to an Outpatient hospital 
facility for hospital outpatient services. This item/service 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 hospital outpatient services on April 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assessment of and care planning provided on April 20, 2022, 
by an OON provider. 
 
You asked the Plan to pay for assessment of and care planning. You say that the providers rely on the facility 
staff to verify eligibility and obtain authorization from the patient's insurance company. The Plan denied your 
request. The Plan says the out-of-network services were not authorized. 
 
 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 assessment of and care planning provided on April 
20, 2022, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the BRCA 1/2 genetic analysis provided to the enrollee on
November 16, 2021.
You asked the Plan to pay for the BRCA 1/2 genetic analysis. You say that this testing was medically
necessary. The Plan denied your request. The Plan says that no test results were submitted to support the billing
of this code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 81162 is BRCA1 (BRCA1, DNA repair associated),
BRCA2 (BRCA2, DNA REPAIR associated) (eg, hereditary breast and ovarian cancer) gene analysis; full
sequence analysis and full duplication/deletion analysis (ie, detection of large gene rearrangements).
We find that CPT code 81162 is not supported in the medical record. Specifically, the lab results state that the
test performed did not include analysis of the BRCA1 and BRCA2 genes. Based on this information, we
decided that Medicare rules for coverage of the BRCA 1/2 genetic analysis have not been met. Therefore, we
decided that the Plan does not have to pay for the BRCA 1/2 genetic analysis provided to the enrollee on
November 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit services provided on January 25, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for office visit services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 office visit services provided on January 25, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided on May 17, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for injections. You say that you would like to request reconsideration of the denied 
claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is required 
prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for injections provided on May 17, 2022, by an out-
of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs (A9270) provided on June 9, 
2022 and July 7, 2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not covered under your contractual 
policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs provided are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
(A9270) provided on June 9, 2022 and July 7, 2022.  Benefits for these items may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electromyography (EMG) provided on 
June 10, 2022. 
 
You asked the Plan to waive the copayment for an electromyography (EMG). You say that your treatment plan 
does not include an EMG and you refuse to pay for it. 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 $15 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $15 copayment for an electromyography (EMG). 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 an electromyography (EMG) provided on June 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care (99222) and bladder irrigation 
(51700) provided on June 5, 2022. 
 
You asked the Plan to pay for the initial hospital care and bladder irrigation. You say that you would like to 
appeal these services. The Plan denied your request. The Plan says these services were denied at the time the 
authorization/pre-certification was requested. The Plan also says that these services were denied due to 
insufficient clinical information, and no additional medical records had been received. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the initial hospital care (99222) and 
bladder irrigation (51700) provided on June 5, 2022. have been met. Medical records were not provided with 
this case. Without this information, we cannot determine if the services provided were medically necessary. 
Therefore, we decided that the Plan does not have to pay for the initial hospital care (99222) and bladder 
irrigation (51700) provided on June 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on June 21, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that you need an eye refraction every year because 
you have a medical condition with your eyes and your prescription keeps changing. You also say that you feel 
this charge should be covered because of your condition. The Plan denied your request. The Plan says the eye 
refraction is not a covered benefit since it was performed during a medical vision check. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers eye refractions performed during a routine exam. 
 
We looked at the file and the Plan's rules. The record shows that you received a medical vision check for 
endothelial corneal dystrophy. Based on this information, we decided that the Plan's rules for coverage of the 
eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye 
refraction (92015) provided on June 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot orthotics (L3000) provided on April 14, 2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not a covered benefit under your 
contractual policy or by Medicare for your condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
The records provided do not show that you suffer from diabetic foot disease or wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for the foot orthotics (L3000) provided on 
April 14, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the splint refitting provided on July 05, 
2022. 
 
You asked the Plan to waive the copayment for the splint refitting. You say that you needed the splint loosened 
and the provider still made it too tight. 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 $35 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $35 copayment for the splint refitting. This item/service falls within the 
outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan.  Therefore, we decided that the Plan does not have to waive the copayment for 
the splint refitting provided on July 05, 2022.