Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an acute inpatient hospital stay provided 
from May 28, 2022, to May 31, 2022. 
 
You asked the Plan to waive the copayment for an acute inpatient hospital stay. You say that you were 
admitted at one hospital facility and then transferred to another. You say this should not be your responsibility. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment per day for days 1 to 5 and $0 after day 5 each time you are admitted to an acute care hospital.  
 
You have been asked to pay $825 for a 3-day acute inpatient hospital stay ($275 per day x 3 days = $825). This 
item/service falls within the Inpatient Hospital Care benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for an acute inpatient hospital stay provided from May 28, 2022, to May 31, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance ride provided on March 08, 
2022. 
 
You asked the Plan to waive the copayment for an ambulance ride. You say that you were told by your treating 
provider that this service would be covered at no cost to you. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for ambulance services. 
 
You have been asked to pay a $275 copayment for an ambulance ride. This item/service falls within the 
ambulance services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan.  Therefore, we decided that the Plan does not have to waive the copayment for an ambulance ride 
provided on March 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on January 17, 
2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you would like the deductible to be 
reviewed. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $185 deductible which applies to Physician/Practitioner services 
including doctor's office visits.  
 
The item or service you asked the Plan to waive the copayment for falls within the benefit category 
Physician/Practitioner services including doctor's office visits. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $185 deductible which applies to Physician/Practitioner Services 
Including Doctor's Office Visits. This cost sharing is a contractual obligation that had not been met at the time 
an office visit was received on January 17, 2022. Therefore, $77.62 was applied to the deductible. We decided 
that the Plan does not have to waive the copayment for an office visit provided on January 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on March 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 this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for specialist office visits. Covered services include consultation, diagnosis, treatment by a 
specialist. 
 
You have been asked to pay a $25 copayment for office visit. This item/service 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 office visit on March 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a bladder procedure provided on July 12, 
2021. 
 
You asked the Plan to waive the coinsurance for a bladder procedure. You say that the provider left scar tissue 
from the first surgery, which is why you had to have this second procedure. You feel that since this was the 
provider's error, you should not have to pay this coinsurance. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 10% 
coinsurance for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers. The allowed amount of this item or service was $3,569.72, resulting in a 
coinsurance of $356.97 ($3,569.72 x 10% = $356.97). 
 
 You have been asked to pay a $356.97 coinsurance for a bladder procedure. This item/service falls 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 waive the coinsurance for a bladder procedure provided 
on July 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a denosumab injection provided on May 
25, 2022. 
 
You asked the Plan to waive the coinsurance for a denosumab injection. You say that you have not had to pay 
for this service before The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for a denosumab injection. This item/service falls within the 
Medicare Part B prescription drugs 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 denosumab injection provided on May 25, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy with polyp removal 
provided on June 13, 2022. 
 
You asked the Plan to waive the copayment for a colonoscopy with polyp removal. You say that you disagree 
with the copayment and believe it should not have been applied. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment for outpatient surgery. 
 
You have been asked to pay a $300 copayment for a colonoscopy with polyp removal. This item/service falls 
within the outpatient surgery 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 
colonoscopy with polyp removal provided on June 13, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for 10 days of a SNF COVID-19 isolation 
provided from May 1, 2022, to May 31, 2022. 
 
You asked the Plan to waive the copayment for 10 days of a SNF COVID-19 isolation. You say that you were 
told that COVID-19 was covered at 100%. You say that you feel this was a wasted admission. The Plan denied 
your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay $0 copayment for days 1 to 20 and a $188 copayment for days 21 to 53 for skilled nursing facility 
stay.  
 
 
  The enrollee has been asked to pay $1,880 for 10 days of a SNF COVID-19 isolation ($188 per day x 10 days = 
$1,880). This item/service falls within the Skilled Nursing Facility (SNF) Care benefit category. This means 
that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing 
is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the 
Plan does not have to waive the copayment for 10 days of a SNF COVID-19 isolation provided from May 1, 
2022, to May 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychiatry services provided on June 21, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the out-of-network psychiatry services. You say that you have been seeing this 
provider for years and do not want to change doctors. The Plan denied your request. The Plan says 
unauthorized, out-of-network care is not covered. 
 
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 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 psychiatry services provided on June 21, 2022 by 
an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-transport ambulance services you received on March 15, 
2022. 
 
You asked the Plan to pay for the non-transport ambulance services. You say that you had a car accident and 
the police called an ambulance.  You assumed that the Plan would cover this cost. The Plan denied your 
request. The Plan says non-transport ambulance services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 15, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for non-transport ambulance services you received on 
March 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an ultrasound provided on March 23, 2022. 
 
You asked the Plan to waive the deductible for an ultrasound. You say that you disagree with the bill for a 
$214.53 deductible that you received. You say that you only had a $45 copayment and should not have a 
deductible on the plan. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible which applies to Medicare-covered radiological 
diagnostic services, not including X-rays, performed in a physicians office or at a free-standing facility (such 
as a radiology center or medical clinic).  
 
The item or service you asked the Plan to waive the deductible for falls within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $750 deductible which applies to Medicare-covered radiological 
diagnostic services, not including X-rays, performed in a physicians office or at a free-standing facility (such 
as a radiology center or medical clinic). This cost sharing is a contractual obligation that had not been met at 
the time an ultrasound was received on March 23, 2022. Therefore, $214.53 has been applied to the deductible. 
We have decided that the Plan does not have to waive the deductible for an ultrasound provided on March 23, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (code 99202) you had with a chiropractor on 
May 17, 2022. 
 
You asked the Plan to pay for the office visit. You say that you would like this claim paid because you are 
unable to write and drive due to arthritis. The Plan denied your request. The Plan says office visits are not 
covered chiropractic services. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (code 99202) you had with a chiropractor on May 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided on June 
08, 2022, to June 10, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you should not be 
responsible to pay this. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $650 
copayment for inpatient hospital care. 
 
You have been asked to pay a $650 copayment for an inpatient hospital stay. This item/service falls within the 
inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan.  Therefore, we decided that the Plan does not have to waive the copayment for an inpatient 
hospital stay provided on June 08, 2022, to June 10, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for emergency room services on May 24, 
2022, to May 25, 2022. 
 
You asked the Plan to waive the copayments for emergency room services. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110 
copayment for each covered emergency room visit. 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. There were 2 visits. $110 x 2 = $220. Therefore, results in the total cost sharing amount of $220. 
 
 
 
 
 You have been asked to pay a $110 copayment for each emergency room services. This item/service 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 copayments for emergency 
room services on May 24, 2022, to May 25, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy visits provided on April 
13, 2022, to April 30, 2022. 
 
You asked the Plan to waive the copayment for physical therapy visits. You say that you were not informed 
there would be a copayment and you feel this should be covered under your emergency care The Plan denied 
your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $175 
copayment for Outpatient rehabilitation services. 
 
You have been asked to pay a $175 copayment for physical therapy visits. This item/service falls within the 
Outpatient rehabilitation 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 
physical therapy visits provided on April 13, 2022, to April 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on April 22, 
2022. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you are requesting a 
reconsideration of the cost-share for laboratory work. You say that you can not recall paying a cost-share for 
lab work in the past. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $50 copayment for laboratory services. This item/service falls within the 
outpatient diagnostic test benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan.  Therefore, we decided that the Plan does not have to waive the copayment for laboratory 
services provided on April 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs (Buspirone, Lisonopril, Aspirin, 
Escitalopram oxalate, Carvedilol, Simvastatin, and Levothyroxine) provided during an outpatient hospital stay 
from August 8, 2021, to August 10, 2021. 
 
You asked the Plan to pay for the self-administered drugs. You say that these drugs were prescriptions required 
by the enrollee's physician and should be covered. The Plan denied your request. The Plan says self-
administered drugs are not covered under the patient's medical benefits. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
(Buspirone, Lisonopril, Aspirin, Escitalopram oxalate, Carvedilol, Simvastatin, and Levothyroxine) provided 
during an outpatient hospital stay from August 8, 2021, to August 10, 2021.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided November 17, 2021 to 
November 23, 2021. 
 You asked the Plan to pay for the inpatient hospital care. You say that this service was medically necessary and 
properly billed. The Plan denied your request. The Plan says records do not support the diagnosis codes billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis codes A41.50 and J15.6. We asked our 
physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the inpatient hospital care. Our reviewer says that the records 
do not support the diagnosis codes billed. Our physician reviewer found neither gram-negative pneumonia nor 
sepsis could be clinically validated. The review has determined that the records did not support diagnosis codes 
A41.50 and J15.6.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital care provided November 17, 2021 to November 23, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on May 07, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you feel this should be covered 
because you should only have a $10 copayment for a primary care provider visit, as listed on your card. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $100 copayment for an ultrasound. This item/service falls within the outpatient 
diagnostic test 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 
May 07, 2022.