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

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services provided 
on November 27, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the services should 
be covered as it was not your choice to receive them. 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 $175 
copayment for Ambulance Services.  
 
You have been asked to pay a $175 copayment for an ambulance transportation. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for ambulance transportation services provided on November 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) provided on 
August 31, 2021. 
 
You asked the Plan to waive the copayment for an EKG. You say that the copayment for this service should 
have been included with the surgery that took place. The Plan denied your request. The Plan says the proper 
copayment was applied for this service. 
 
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 Diagnostic procedures and tests at an outpatient hospital setting.  
 
  You have been asked to pay a $50 copayment for an EKG. An EKG 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 electrocardiogram (EKG) provided on August 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a pneumatic compressor and leg 
appliances provided on June 29, 2021. 
 
You asked the Plan to waive the coinsurance for the compressor and appliances. You say that the claim should 
be paid in full based on your policy and current requirements. 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 durable medical equipment (DME), including pneumatic compression devices. 
 
 Item Allowed Amount 20% Coinsurance 
Pneumatic Compressor (E0652) $4,721.00 $944.20 
Segmental Appliance Left (E0667) $288.32 $57.66 
Segmental Appliance Right (E0667) $288.32 $57.66 
Total:  $1,059.52 
 
You have been asked to pay $1,059.52, which is 20% of the allowed amount for the compressor and 
appliances. The compressor and appliances fall within the Durable Medical Equipment (DME) and Related 
Supplies benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a pneumatic compressor 
and leg appliances provided on June 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a visual field examination (92083) and a scanning 
computerized ophthalmic diagnostic imaging (92133) provided on April 27, 2021, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for a visual field examination and a scanning computerized ophthalmic diagnostic 
imaging. You say that you are appealing with supporting records. The Plan denied your request. The Plan says 
they determined that both the referring and attending providers are all non-participating with the Plan, and the 
non-participating provider did not follow the Plan's rules to request authorization for out-of-network care. 
 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 a visual field examination (92083) and a scanning 
computerized ophthalmic diagnostic imaging (92133) provided on April 27, 2021, by an out-of-network (OON) 
provider.
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 2, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that it is unfair to have a copayment. The 
Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for each emergency room visit.  
 
You have been asked to pay a $90 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 2, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy (EGD) 
with biopsy performed on October 12, 2021. 
 
You asked the Plan to waive the copayment for the EGD with biopsy. You say that your copayment amount 
should have also been taken care of by the Plan. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment per visit for outpatient surgery or procedure at an outpatient hospital facility.  
 
You have been asked to pay $161.92, which is less than the $200 copayment for the EGD with biopsy. The EGD with biopsy falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient 
Facilities and Ambulatory Surgical Centers benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for an esophagogastroduodenoscopy (EGD) with biopsy performed on October 12, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy (EGD) 
with biopsy performed on October 14, 2021. 
 
You asked the Plan to waive the copayment for the EGD with biopsy. You say that you were not made aware 
of the copayment prior to the procedure. 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 $400 
copayment for each outpatient surgery at an outpatient hospital facility.  
 
You have been asked to pay a $400 copayment for the EGD with biopsy. Please note that while you did have a 
colonoscopy along with this procedure, only one copayment applies. The EGD with biopsy falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for an 
esophagogastroduodenoscopy (EGD) with biopsy performed on October 14, 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 29, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you were informed that the 
copayment would be waived due to your COVID-19 diagnosis. 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 $90 
copayment per visit for emergency care.   
The file shows that COVID-19 cost share waivers ended May 31, 2021. Therefore, you have been asked to pay 
a $90 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 29, 2021.  
 
Your complaint about Plan customer service representatives giving you the wrong information is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy services (S9338) provided on July 
9, 2021. 
 
You asked the Plan to pay for code S9338. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. In this case, CPT code S9338 has a status code of "I" under the 
Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses 
another code for reporting of, and payment for, this service. Therefore, we decided that the Plan does not have 
to pay for the home infusion therapy services (S9338) provided on July 9, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the office visit (99214) provided on May 24, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the copayment has been applied correctly 
to the service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $0 copayment for each Medicare-covered primary care 
doctor office visit and a $40 copayment for each Medicare-covered specialist visit.   
 
The Plan says you must pay a $40 copayment for a Medicare-covered specialist visit provided. Based on the 
Plan contract, however, you cannot be asked to pay more than a $0 copayment for the service rendered as this 
provider is indicated as a Family Nurse Practitioner, primary care provider type. Therefore, we decided that the 
Plan has to waive the copayment for the office visit (99214) provided on May 24, 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 an ultrasound provided on January 19, 
2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that the services should be covered. 
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 $160 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
 
  You have been asked to pay a $160 copayment for an ultrasound. Ultrasounds 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 an ultrasound provided on January 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99213) provided on August 19, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the claim was denied for unauthorized services, and the servicing provider 
is not a participating provider with 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 (99213) provided on August 19, 
2021, 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 the fine needle aspiration biopsy, including 
ultrasound guidance (10005) provided on September 22, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service 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 $350 
copayment per date of service at an outpatient hospital facility.  
 
You have been asked to pay a $350 copayment for the surgery provided at an outpatient hospital facility. 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 fine needle aspiration biopsy, including 
ultrasound guidance (10005) provided on September 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the office visit (99213), the colonoscopy 
with lesion removal (45385), and the colonoscopy with biopsy (45380) provided on November 5, 2021 and 
November 18, 2021. 
 
You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to 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 $200 copay per visit, per provider, per day for 
surgery performed in an outpatient hospital setting. Additionally, if a colorectal cancer screening test results in 
biopsy or removal of a lesion or growth, the procedure is considered diagnostic and outpatient surgery cost 
sharing may apply. Enrollees pay a $35 copayment per specialist visit. 
 
You have been asked to pay $235 which includes a $200 copayment for the Medicare-covered surgery and a 
$35 copayment for the specialist visit provided. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for the office 
visit (99213), the colonoscopy with lesion removal (45385), and the colonoscopy with biopsy (45380) provided 
on November 5, 2021 and November 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth facility fee (Q3014) provided on November 18, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for telehealth facility fee. You say that the patient has been coming to you since 
prior to the Plan effective date. The Plan denied your request. The Plan says this provider is not a network 
provider with the Plan, and they have also determined that these services are not urgent or emergent, nor were 
they approved in advance. 
 
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 telehealth facility fee (Q3014) provided on 
November 18, 2021, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided 
from September 12, 2021, to September 16, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you were admitted from the ER and 
should not have to pay the copayment. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for each emergency room visit. The cost sharing is only waived if you receive care from a primary 
care provider (PCP), urgent care provider, or LiveHealth Online within 24 hours prior to the ER visit.   
The file does not show that you received care from your PCP, urgent care, or LiveHealth Online within 24 
hours prior to your ER visit. Therefore, you have been asked to pay a $90 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 from September 12, 2021, to September 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the home ventilator provided on October 
12, 2020. 
 
You asked the Plan to waive the coinsurance for the home ventilator. You say that you feel you should not have 
to pay the coinsurance for the home ventilator. The Plan denied your request. The Plan says the coinsurance 
applied 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 20% 
coinsurance for DME and related supplies. The total cost of the ventilator approved by the Plan is $1108.91, 
making your total coinsurance $221.78 ($1108.91 x 20%). 
 You have been asked to pay 20% coinsurance for the home ventilator. The home ventilator falls within the 
Durable medical equipment (DME) and related supplies benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the coinsurance for the home ventilator provided on October 12, 2020.