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

 
We decided that the Plan does not have to waive the copayment for lab services provided on March 28, 2022. 
 
You asked the Plan to waive the copayment for lab services. You say that you should not have this copayment. 
The Plan denied your request. The Plan says the copayment 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 $45 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay the allowed amount of $36.88 which is less than the $45 copayment for lab 
services. Lab services falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 
benefit category. The records show the laboratory services were provided during a general adult examination 
and were billed by the hospital 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 lab services provided on 
March 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for home oxygen equipment provided on 
April 22, 2022. 
 
You asked the Plan to waive the coinsurance for home oxygen equipment. You say that you no longer have this 
equipment and should not have to pay anymore. The Plan denied your request. The Plan says the cost sharing 
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 20% 
coinsurance for durable medical equipment (DME). The allowed amount of this item is $146.05 resulting in a 
coinsurance amount of $29.21 ($146.05 x 20% = $29.21). 
 
You have been asked to pay a $29.21 coinsurance for home oxygen equipment. Home oxygen equipment 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 home oxygen equipment provided on April 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a drug test provided on December 8, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a drug test. 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 it was determined these 
services can be received in-network. 
 
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 drug test provided on December 8, 2021, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 22, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service February 22, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cardiac device monitoring services 
provided on September 21, 2021. 
 
You asked the Plan to waive the copayment for cardiac device monitoring services. You say that you should 
not have to pay this copayment. The Plan denied your request. The Plan says the copayment 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 $50 
copayment for diagnostic procedures and tests in a specialist's office.  
 
You have been asked to pay the allowed amount of $45.39 which is less than the $50 copayment for cardiac 
device monitoring services. Cardiac device monitoring services falls within the Diagnostic Procedures and 
Tests in a Specialist's Office 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 cardiac device monitoring services provided on September 
21, 2021.  
 
Your complaint that the Plans customer service department gave you incorrect 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics. 
 
You asked the Plan to pay for foot orthotics. You say that you were told these would be covered up to 80%. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
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.   
 
Records show that you do not suffer from diabetic foot disease and you do not 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 foot orthotics.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
from February 16, 2022, to March 13, 2022. 
 
You asked the Plan to waive the copayment for the SNF care. You say that you feel the stay was pointless as 
you were not treated. 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 $0 per 
day for days 1-20 and $176 per day for days 21-100 for each benefit period. 
 
Dates of Service Benefit Days Copayment 
February 16, 2022  March 7, 2022 1-20 (20) $0/day 
March 8, 2022  March 13, 2022 21-26 (6) $176/day 
Total:  $1,056 The file shows that you were in the skilled nursing facility from February 16, 2022, to March 13, 2022. 
Therefore, you have been asked to pay $176 per day for days 21-26 of SNF care, for a total of $1,056. The SNF 
care falls within the Skilled Nursing Facility (SNF) Care benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for skilled nursing facility (SNF) care provided from February 16, 2022, to March 13, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services you received on April 21, 2022. 
 
You asked the Plan to pay for the chiropractic services. You say that you need chiropractic care for diffuse 
idiopathic skeletal hyperostosis and arthritis of the neck area. The Plan denied your request. The Plan says this 
service was not billed with the appropriate modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare requires that the AT modifier must be 
added to chiropractic claims in order to be paid.  The chiropractor that provided these services did not bill with 
the AT modifier, so this claim cannot be paid. You have the right to go to the chiropractor and request that they 
correct this billing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the chiropractic services have not been met. Therefore, we decided that the Plan does not have to 
pay for chiropractic services you received on April 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 24, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. 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 it was 
determined these services can be received in-network. 
 
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 provided on February 24, 2022, by 
an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient injection therapy provided on March 9, 2022. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says you did not have prior 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 outpatient 
injection therapy provided on March 9, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services (ER) on April 18, 
2022. 
 
You asked the Plan to waive the copayment for emergency room services (ER). You say that you feel that the 
manufacturer of the drug should be responsible for any out-of-pocket cost due to your ER visit. 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 $90 
copayment per visit for emergency room services. Emergency care refers to services that are: furnished by a 
provider qualified to furnish emergency services and needed to evaluate or stabilize an emergency medical 
condition. 
 
 
 
 
 You have been asked to pay a $90 copayment for emergency room services (ER). Emergency room services 
(ER) 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 services (ER) on April 18, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the over-the-counter COVID-19 test kit purchased on 
February 15, 2022. 
 
You asked the Plan to pay for the COVID-19 test kit. You say that you believe you should be reimbursed for 
the test kit. The Plan denied your request. The Plan says this claim was processed correctly. The Plan also says 
these test kits are not eligible for reimbursement from the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the 
COVID-19 test kit is an OTC item. The Plan does not offer a supplemental benefit covering this service, as this 
is not currently required by Medicare. However, for future purchases, these can be obtained with participating 
providers and covered by Original Medicare when using your Medicare card rather than your Plan card. 
Neither Medicare nor your Plan currently offers reimbursement of purchased COVID-19 tests. Therefore, we 
decided that the Plan does not have to pay for the over-the-counter COVID-19 test kit purchased on February 
15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on December 1, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for genetic testing. You say that you would like to appeal the denial of the claim. 
The Plan denied your request. The Plan says the test was ordered inappropriately, and the provider was not this 
members doctor at the time 
the test was ordered. 
 
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 genetic testing provided on December 1, 2021, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve the portable oxygen concentrator. You say that this portable oxygen 
concentrator is medically necessary. The Plan denied your request. The Plan says the requested equipment is 
primarily for use outside the home and is non-covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a prosthetic fitting provided on October 
21, 2021. 
 
You asked the Plan to waive the coinsurance for a prosthetic fitting. You say that you cannot afford this 
coinsurance charge at this time. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for prosthetic devices and related supplies. The allowed amount of this item is $98.70 resulting in a 
coinsurance amount of $19.74 ($98.70 x 20% = $19.74) there was a $0.24 non covered item that was also 
applied ($19.74 + 0.24 = $19.98). 
 
You have been asked to pay a $19.98 coinsurance for a prosthetic fitting. A prosthetic fitting 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 a prosthetic fitting provided on October 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have pay additional reimbursement for the walker seat attachment provided 
on January 14, 2022. 
 
You asked the Plan pay additional reimbursement for the walker seat attachment. You say that there is a 
mistake somewhere in the processing of this claim. 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 30% 
coinsurance for out-of-network durable medical equipment.  
 
You have been reimbursed $13.01 for out-of-network durable medical equipment which is the allowed amount 
minus a 30% coinsurance ($18.59 the allowed amount  $5.58 the coinsurance = $13.01). The walker seat 
attachment 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 pay additional reimbursement for the walker seat attachment provided on January 14, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided to the enrollee on January 6, 2022. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior 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 must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 medical services provided to the enrollee on 
January 6, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you should not have to 
pay this copayment. The Plan denied your request. The Plan says you were charged this cost sharing correctly. 
There was no inpatient admission for this date of 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 $75 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $75 for these services. 
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 ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit with an extremity study, an 
ultrasound study of arm and leg arteries provided on January 17, 2022. 
 
You asked the Plan to waive the copayment for the office visit and extremity study. You say that there should 
only be one copay of $25 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 $25 
copayment per visit for podiatry services, and a $25 copayment for a peripheral vascular ultrasound.  
 You have been asked to pay two $25 copayments for the office visit and extremity study for a total of $50. The 
office visit falls within the Podiatry Services benefit category. The extremity study falls with the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for the office visit with an extremity study, an ultrasound study of arm and leg arteries provided 
on January 17, 2022.