Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the office visits you had with an
orthopedic surgeon on February 5, 2021, March 1, 2021, March 29, 2021, April 26, 2021, May 24, 2021, June
23, August 18, 2021, and October 6, 2021, and the magnetic resonance imaging (MRI) you had on February 22, 2021.
You asked the Plan to waive the copayments for the specialist visits and the MRI. You say that you would like
all of these copayments waived because your previous doctor failed to diagnose your fracture. The Plan denied
your request. The Plan says you were charged these copayments correctly. The Plan says that for the MRI,
because the allowed amount for this service ($230.28) is less than your copayment obligation, you are
responsible for the full allowed amount 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 $35
copayment for specialist visits and a $325 copayment for diagnostic radiology services.
You have been asked to pay a $35 copayment for the specialist visits and a $325 copayment for the MRI. The
MRI falls within diagnostic radiology services benefit category. This means that you have been asked to pay
the correct amounts based on your contract with the Plan. These copayments apply regardless of the reason for
these services. 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 the office visits you had with an
orthopedic surgeon on February 5, 2021, March 1, 2021, March 29, 2021, April 26, 2021, May 24, 2021, June
23, August 18, 2021, and October 6, 2021, and the magnetic resonance imaging (MRI) you had on February 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an eye prosthetic provided on November 10, 2021.
You asked the Plan to waive the coinsurance for an eye prosthetic. You say that you pay a high monthly premium and disagree with having to pay for your eye prosthesis. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 nothing for surgically implanted prosthetic devices and related medical supplies and 20% coinsurance for external prosthetic devices and related supplies. You received an eye prosthetic on November 10, 2021. This is considered an external prosthetic. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $649.61 and 20% of that is $129.92.
You have been asked to pay the total coinsurance amount of $129.92 for an eye prosthetic. An eye prosthetic 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 an eye prosthetic provided on November 10, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound you had on September 30, 2021.
You asked the Plan to waive the copayment for the ultrasound. You say that you have had this procedure at the
same facility in previous years and did not pay this much. The Plan denied your request. The Plan says you
were charged this copayment correctly. The Plan says that because the allowed amount for this service ($94.38)
is less than your copayment obligation, you are responsible for the full allowed 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 $105
copayment for radiological diagnostic services.
You have been asked to pay a $105 copayment for the ultrasound. The ultrasound falls within the radiological
diagnostic services benefit category. This copayment applies regardless of what you may have paid for this
service in previous years. 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 ultrasound you had on September 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a walking boot provided on October 7, 2021.
You asked the Plan to waive the coinsurance for the walking boot. You say that the hospital staff informed you
that the walking boot was included in the ER services. 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 each prosthetic or orthotic device, including braces.
You have been asked to pay $39.06, which is 20% of the allowed amount for the walking boot ($195.32
allowed amount x 20% coinsurance = $39.06). The walking boot 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 walking boot
provided on October 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 5, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the provider did not bill as required by Medicare coding regulations.
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 71250 is a column II code to column I code 71275. 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 imaging services provided to the enrollee on October 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation services provided on September 8, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that the ambulance was medically necessary and you did not receive a bill until November. 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 one-way ambulance trip. You have been asked to pay a $225 copayment for the ambulance transportation. 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 the copayment for ambulance transportation services provided on September 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a prostatectomy procedure performed on September 28, 2021.
You asked the Plan to waive the copayment for the prostatectomy. You say that you were not aware of 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 $300
copayment per visit for surgery.
You have been asked to pay a $300 copayment for the prostatectomy. The prostatectomy falls within the
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical
Centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a prostatectomy procedure performed on September 28, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for out-of-network psychiatry services you received on February 21, 2020.
You asked the Plan to waive the deductible for the out-of-network psychiatry services. You say that this claim should be paid as if it was in-network because there were no network providers in your area. The Plan denied your request. The Plan says you were charged this deductible correctly. The Plan has identified network providers with the same specialty that are located within 30 miles of your home.
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 there is a $750 deductible which applies to out-of-network psychiatry services.
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to out-of-network psychiatry services. This cost sharing is a contractual obligation that had not been met at the time the out-of-network psychiatry services were received on February 21, 2020. Therefore, we decided that the Plan does not have to waive the deductible for out-of-network psychiatry services you received on February 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit (G0463) and laboratory
services (87070, 87205) provided on October 26, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a hospital outpatient clinic visit and laboratory services. You say that you
regularly comply with all administrative requirements for payments. The Plan denied your request. The Plan
says the services were rendered by a non-participating provider and they have also determined that these
services are not urgent or emergent, nor were they approved in advance. The Plan also says that payment was
not allowed because the Plan did not receive a primary care physician (PCP) referral to review and approve.
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 hospital outpatient clinic visit (G0463) and laboratory services (87070, 87205) provided on October 26, 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 the emergency room (ER) visit you had on September 4, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that the provider didn't do anything but take a blood sample and check your blood pressure, so you do not think you should have to pay this copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency services. You have been asked to pay a $90 copayment for the ER visit. This copayment applies each time you visit the ER, regardless of the extent of services you receive. 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 emergency room (ER) visit you had on September 4, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from February 15, 2021, to March 16, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the 100 day benefit has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from August 15, 2020 
to February 14, 2021. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row.  Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to 
the enrollee from February 15, 2021, to March 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
December 21, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you do not believe you 
should owe another copayment for a follow up appointment. 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 $40 
copayment for each specialist office visit.  
 
 
 You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls 
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 a specialist office visit provided on December 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit you had with an 
ophthalmologist on October 22, 2021. 
 
You asked the Plan to waive the copayment for the ophthalmology visit. You say that you had an eye 
appointment on October 4, 2021, that was unsatisfactory, so you had to go again for issues with your eyes.  
You do not think you should have to pay this copayment. The Plan denied your request. The Plan says you 
were charged this copayment 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 $30 
copayment for medical eye exams.  
 
You have been asked to pay a $30 copayment for the ophthalmology visit. This copayment applies regardless of the reason for the visit. 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 you had 
with an ophthalmologist on October 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye exam (92014) provided on 
December 1, 2021. 
 
You asked the Plan to waive the copayment for the eye exam. You say that the services should be covered as it 
was a routine exam. 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 $35 
copayment for Vision Care.  
 
 
 
 
 
 You have been asked to pay a $35 copayment for an eye exam. Eye exams fall 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 an eye exam (92014) provided on December 1, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the orthopedic surgery office visit and the 
x-ray of the foot you received on November 9, 2021. 
 
You asked the Plan to waive the copayments for the specialist visit and the x-ray. You say that you have never 
had to pay a copayment for x-rays in the past. The Plan denied your request. The Plan says you were charged 
these copayments correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for x-rays and a $30 copayment for visits with a specialist.  
 
You have been asked to pay a $30 copayment for the specialist visit and a $35 copayment for the x-ray. These copayments apply regardless of what you pay have paid for similar services in the past. 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 the orthopedic surgery office visit and the x-ray of the foot you 
received on November 9, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on 
November 6, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you should not have a copayment 
because this was a continuation or follow-up for treatment you had received previously. The Plan denied your 
request. The Plan says you were charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for each emergency room visit.  
 
 
 
 
 
 
 You have been asked to pay a $90 copayment for the ER visit. This copayment applies each time you visit the 
ER, regardless of the reason. 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 emergency room (ER) 
visit you had on November 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on May 10, 2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that the services should be covered in 
full because you didn;t see the doctor, only the nurse. 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 $35 
copayment for Physician/Practitioner services, including doctor's office visits.  
 
 
 
 
 
 You have been asked to pay a $35 copayment for an office visit. 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 office visit provided on May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on October 
29, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be 
covered as you received a pelvic and breast exam and there should be no copayment for preventative services. 
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 $50 
copayment for Physician/Practitioner services, including doctor's office visits.  
 
 
 
 
 
 You have been asked to pay a $50 copayment for a specialist office visit. The record indicates that during the 
office visit the provider addressed three diagnoses that were unrelated to the preventative exam, there was no 
copayment applied to the preventative exam, only the office visit.  Specialist 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 a specialist office visit provided on October 29, 2021.