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

 
We decided that the Plan does not have to waive the copayment for a nuclear medicine bone imaging provided 
on April 21, 2022. 
 
You asked the Plan to waive the copayment for the bone imaging. You say that you should not be charged 
again since both procedures were supposed to be done the same day. 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 CT, MRI, PET, and nuclear medicine.  
 
You have been asked to pay a $100 copayment for the bone imaging. The bone imaging 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 a nuclear medicine bone imaging provided on April 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to lower the copayment for the wound care services provided on 
January 18, 2022. 
 
You asked the Plan to lower the copayment for the wound care services. You say that the copayment should be 
less, and you have never paid this much before. The Plan denied your request. The Plan says the proper 
copayment was applied, and they verified with the provider that the service was performed and billed as an 
outpatient in a hospital. 
 
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 each Medicare-covered outpatient hospital facility surgery.  
 
  You have been asked to pay a $275 copayment for the wound care services. The wound care services 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 lower the copayment for the wound care 
services provided on January 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for programming of dual lead pacemaker 
system provided on April 13, 2022. 
 
You asked the Plan to waive the copayment for programming of dual lead pacemaker system. You say that you 
should only pay the copayment for the office visit, not any additional charges. The Plan denied your request. 
The Plan says coinsurance 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 $25 
copayment for in-network and out-of-network, Medicare-covered non-radiological diagnostic services.  
 
You have been asked to pay $25 copayment for programming of dual lead pacemaker system. 
  Date of Service Service Allowed Amount Standard Cost Member Liability 
April 13, 2022 Programming of 
dual lead  
pacemaker 
$85 $25 $25 
TOTAL:    $25 
 
The programming of dual lead pacemaker system 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 
programming of dual lead pacemaker system provided on April 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and a tangential biopsy of skin provided on 
May 11, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and a tangential biopsy of skin. You say that the clinic was 
unaware that a preauthorization was required. The Plan denied your request. The Plan says services from non-
participating providers are not covered unless preauthorized. 
 
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 a tangential biopsy of skin 
provided on May 11, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for outpatient hospital visits provided from 
April 20, 2022, to May 6, 2022. 
 
You asked the Plan to reduce the copayments for the outpatient visits. You say that your specialist copayment 
should only be $30. 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 $225 
copayment for each surgery or service provided at an outpatient hospital.  
 
You have been asked to pay $118.09, which is less than the $225 copayment for each of the outpatient visits, 
for a total of $354.27. The outpatient visits fall within the Outpatient Surgery and Other Medical 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 reduce the copayments for outpatient hospital visits provided from April 20, 2022, to May 6, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an external mobile cardiovascular 
telemetry with electrocardiographic recording for 30 days provided on April 16, 2022. 
 
You asked the Plan to reduce the copayment for an external mobile cardiovascular telemetry with 
electrocardiographic recording for 30 days. You say that the explanation of benefits (EOB) says that the 
procedure code submitted is not eligible for payment. You also say that this should have been covered at 80%. 
The Plan denied your request. The Plan says you were charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for Medicare covered non-radiological diagnostic services.  
 
 You have been asked to pay a $25.13, which is less than the $30 copayment for an external mobile 
cardiovascular telemetry with electrocardiographic recording for 30 days. An external mobile cardiovascular 
telemetry with electrocardiographic recording for 30 days 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 reduce the copayment for 
an external mobile cardiovascular telemetry with electrocardiographic recording for 30 days provided on April 
16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on April 26, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab testing. You say that these services were referred by the enrollee's 
physician. The Plan denied your request. The Plan says the services were provided out-of-network and were 
not 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 the lab testing provided on April 26, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on May 
17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed to switch to a different dentist. The 
Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service November 29, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on May 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for inpatient hospital stay on April 06, 2022. 
 
You asked the Plan to waive the coinsurance for inpatient hospital stay. 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 30% 
coinsurance for each out-of-network Medicare-covered 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. The allowed amount is $6,855.94.  $6,855.94 x 30% = $2,056.78. Therefore, results in the 
total cost sharing amount of $2,056.78. 
 
 
 
 You have been asked to pay a 30% coinsurance for inpatient hospital stay. Inpatient hospital stay 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 coinsurance for inpatient 
hospital stay on April 06, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on March 29, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab testing. You say that the services were referred by the enrollee's 
physician. The Plan denied your request. The Plan says the referring physician and provider are out-of-network 
and were not 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 the lab testing provided on March 29, 2022, by an 
out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care (99337) provided on March 30, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health care. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not 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 the home health care (99337) provided on March 
30, 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 procedure code 20610 billed for date of service April 27, 
2022. 
 
You asked the Plan to pay for procedure code 20610. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 20610 is bundled into payment for 
code 27096. 
 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 20610 
is a column II code to column I code 27096. 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 20610 billed for date of service April 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an echocardiography, transthoracic with doppler provided on 
September 23, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an echocardiography, transthoracic with doppler. You say that you are appealing 
with supporting records. The Plan denied your request. The Plan says no prior authorization was received for 
these services. 
 
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 echocardiography, transthoracic with doppler 
provided on September 23, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic ultrasound provided on April 
22, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic ultrasound. You say that you have a cancer history 
and thought this service would not have a copayment. The Plan denied your request. The Plan says the 
copayment that was applied was 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 $100 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay a $100 copayment for a diagnostic ultrasound. A diagnostic 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 a diagnostic ultrasound provided on April 22, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the copayments for ambulance transportation 
provided on February 6, 2022, and February 9, 2022. 
 
You asked the Plan to waive or reduce the copayments for the ambulance transportation. You say that you 
cannot afford the copayments. 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 $275 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $275 copayment for each ambulance transportation, for a total of $550. The 
ambulance transportation 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 or reduce the copayments for ambulance transportation provided on February 6, 2022, and February 9, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an urgent care visit provided on May 7, 
2022. 
 
You asked the Plan to reduce the copayment for the urgent care visit. You say that you were informed that your 
copayment would only be $10. 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 $65 
copayment for urgently needed services.  
 
You have been asked to pay $35, which is less than the $65 copayment for the urgent care visit. The urgent 
care visit falls within the Urgently Needed 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 reduce the 
copayment for an urgent care visit provided on May 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on January 24, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the skilled nursing facility 
requested your services and typically handle any authorizations if needed. You also say that your services 
would fall under the facility authorization. The Plan denied your request. The Plan says services from non-
participating providers are not covered under the Plan unless preauthorized. 
 
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 subsequent nursing facility care provided on 
January 24, 2022, 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 office visit on May 23, 2022. 
 
You asked the Plan to waive the copayment for office visit. 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 $50 
copayment for specialist visits. Covered services include consultation, diagnosis, and treatment by a specialist.  
 
You have been asked to pay a $50 copayment for office visit. Office visits fall within the Physician/Practitioner 
services, including doctor's office visits benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for office visit on May 23, 2022.