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

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on July 01, 
2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that that this is a high copayment 
for one ambulance ride 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 $350 
copayment for ambulance services. 
 
You have been asked to pay a $350 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 July 01, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for position emission tomography (PET) scan 
on January 19, 2022. 
 
You asked the Plan to waive the copayment for PET scan. 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 $250 
copayment for each Medicare-covered diagnostic radiology service (e.g., CT, MRI, and PET). Covered 
services include but are not limited to other outpatient diagnostic tests including CT scans, MRI and PET scans. 
 
 
 
 
 
 You have been asked to pay a $250 copayment for PET scan. 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 position emission tomography (PET) scan on January 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the out-of-network specialist office visit 
provided on June 15, 2022. 
 
You asked the Plan to reduce the copayment for the out-of-network specialist office visit. You say that the 
doctor is in-network. 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 $65 
copayment for physician/practitioner services, including doctors office visits (out-of-network). 
 
You have been asked to pay a $65 copayment for the out-of-network specialist office visit. This item/service 
falls within the physician/practitioner services, including doctors office visits (out-of-network) 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 the Plan verified the provider is not a network provider. Therefore, we decided that the Plan does not have 
to reduce the copayment for the out-of-network specialist office visit provided on June 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the duplex scan (ultrasound) of extracranial 
arteries provided on May 02, 2022. 
 
You asked the Plan to waive the copayment for the duplex scan (ultrasound) of extracranial arteries. You say 
that the test was ordered by your cardiologist. 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 $170 
copayment for radiological diagnostic services, not including x-rays. 
 
You have been asked to pay a $170 copayment for the duplex scan (ultrasound) of extracranial arteries. This 
item/service falls within the radiological diagnostic services, not including x-rays 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 duplex scan (ultrasound) of extracranial arteries provided on May 
02, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) on 
April 01, 2022. 
 
You asked the Plan to waive the copayment for MRI. 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 $275 
copayment for advanced imaging services at outpatient hospital. Covered services include, but are not limited 
to other outpatient diagnostic tests. 
 
You have been asked to pay a $275 copayment for MRI. 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 magnetic resonance imaging (MRI) on April 01, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lidocaine patch. 
 
You asked the Plan to pre-approve a lidocaine patch. The Plan denied your request. The Plan says this is not 
covered under the enrollee's Part B plan. 
 
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 requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve a lidocaine patch.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance ride provided on November 
17, 2021. 
 
You asked the Plan to waive the copayment for an ambulance ride. You say that you were told that there 
wouldnt be a copayment for this service. 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 ambulance services. 
 
You have been asked to pay a $200 copayment for an ambulance ride. 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 an ambulance ride 
provided on November 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a knee injection provided on April 28, 
2022. 
 
You asked the Plan to waive the copayments for the knee injection. You say that you had one injection done by 
a nurse. 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$275 
copayment for outpatient hospital facility visits.  
 You have been asked to pay $254.50 for the outpatient clinic visit, which is less than the $275 copayment per 
the EOC. This item/service falls within the outpatient hospital facility visits benefit category. You have also 
been asked to pay a $45 copayment for the specialist visit. This item/service falls within the 
physician/practitioner services, including doctor's office visits benefit category. The total for all services is 
$299.50. 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 a knee injection provided on April 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound provided on May 05, 2022. 
 
You asked the Plan to waive the copayment for ultrasound. You say that you should not be responsible to pay 
this. 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 $75 
copayment for ultrasound. 
 
You have been asked to pay a $75 copayment for ultrasound. This item/service falls within the ultrasound 
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 provided on May 05, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for echocardiography provided on May 27, 
2022. 
 
You asked the Plan to waive the copayment for echocardiography. You say that you cannot afford to pay this 
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 $180 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $180 copayment for echocardiography. 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 echocardiography provided on May 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on June 01, 
2022, to June 04, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you should not be 
responsible to pay this. 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 $285 
copayment for inpatient hospital care. 
 
You have been asked to pay a $285 copayment for inpatient hospital care. 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 care provided on June 01, 2022, to June 04, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for prosthetic devices provided on June 21, 
2022. 
 
You asked the Plan to waive the coinsurance for prosthetic devices. You say that you are breast cancer 
survivor, and the prosthetics are necessary. You say that you should not be required to pay for them because the 
Plan says prosthetics are covered for a patient who has had a mastectomy. 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 20% 
coinsurance for Medicare-covered prosthetic devices, supplies related to prosthetic devices, and orthotics.  
 
 
  You have been asked to pay a coinsurance of $137.21, which is 20% coinsurance for prosthetic devices.  
 
Service Type and Code Amount Allowed Cost per Contract Member Liability 
Breast Prosthesis (L8030) $279.41 20% $55.88 
Breast Prosthesis (L8020) $166.86 20% $33.37 
Breast Prosthesis (L8000) $177.12 20% $35.42 
Nipple Prosthesis (L8032) $62.72 20% $12.54 
Total   $137.21 
 
This item/service falls within the Prosthetic Devices 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 prosthetic devices provided on June 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on April 15, 
2022. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you are appealing the 
copayment for lab services because you feel that you should not owe anything. 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 $40 
copayment for laboratory tests performed at an outpatient hospital.  
 
You have been asked to pay $26.03, which is less than the standard $40 copayment for laboratory services 
performed at an outpatient hospital. 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 
laboratory services provided on April 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and x-rays provided on May 10, 2022, by an 
OON provider. 
 
You asked the Plan to pay for an office visit and x-rays. You say that the front office called for benefits and 
were told the patient was out-of-network but were not told that authorization was needed. 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 an office visit and x-rays provided on May 10, 
2022, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a refraction provided on March 7, 2022. 
 
You asked the Plan to waive the copayment for a refraction. You say that you are requesting a reconsideration 
of the cost share charges. 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 $45 
copayment for Medicare-covered exams to diagnose and treat diseases and conditions of the eye.  
 
 
  You have been asked to pay a $30 copayment for a refraction. Refractions are not normally covered unless 
provided with a routine eye exam, but this service was covered as a Medicare covered eye exam. A $30 
copayment is less than the standard $45 copayment for a Medicare-covered 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 waive the copayment for a refraction 
provided on March 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an acute inpatient hospital stay provided on 
December 06, 2021, to December 09, 2021. 
 
You asked the Plan to waive the copayment for an acute inpatient hospital stay. You say that you are 
experiencing a financial hardship and unable to pay the $300 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 $300 
copayment for inpatient hospital care. 
 
You have been asked to pay a $300 copayment for an acute 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 
an acute inpatient hospital stay provided on December 06, 2021, to December 09, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review has determined that the requested Intracept procedure is not medically 
reasonable and necessary for the enrollee in this case. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service June 5, 2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976.  
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, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service June 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet block injections. 
 
You asked the Plan to pre-approve facet block injections. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet specific criteria. 
 
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 facet block injections. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found in this case, the enrollee has 
radiculopathy. The review has determined that the enrollee does not meet the coverage criteria detailed in the 
LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet block injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet block injections.