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

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
November 26, 2021, to November 28, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you do not know what the bill 
was for. The Plan denied your request. The Plan says the enrollee has 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $200 copayment for each inpatient admission.  
 
The enrollee has been asked to pay a $200 copayment for the inpatient care. The inpatient care falls within the 
Inpatient Hospital 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 
inpatient hospital care provided from November 26, 2021, to November 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
December 13, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you disagree with this 
charge. The Plan denied your request. The Plan says the copayment amount 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 
copayment for specialist office visits.  
 
You have been asked to pay a $30 copayment for the specialist office visit. Specialist office visits fall within 
the Physician/Practitioner Services, Including Doctors 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 the specialist office visit provided on December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transitional care management services and a domiciliary or 
rest home visit provided on December 8, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for transitional care management services and a domiciliary or rest home visit. You 
say that this provider was not responsible to obtain authorization, and the assisted living facility is responsible 
to obtain prior authorization for all of their patients. The Plan denied your request. The Plan says this provider 
is out-of-network with the Plan, and authorization was not obtained prior to the services being rendered. 
 
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 transitional care management services and a 
domiciliary or rest home visit provided on December 8, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
November 1, 2021, to November 5, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you do not know what the bill 
was for. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for each inpatient admission.  
 
You have been asked to pay $135.69, which is less than the $200 copayment for the inpatient care. The 
inpatient care 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 inpatient hospital care provided from November 1, 2021, to November 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 7, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you believed that there was an approved 
authorization prior to treating the enrollee. The Plan denied your request. The Plan says the rendering provider 
is an out-of-network provider and there was no referral from an in-network provider or an approved 
authorization. 
 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 July 7, 2021, by an out-
of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for physical therapy (PT) services provided on 
December 14, 2021. 
 
You asked the Plan to reduce the copayment for the PT services. You say that you thought your copayment was 
only $10. You say that you cannot afford to continue PT with the $35 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 $35 
copayment for each therapy visit.  
 You have been asked to pay a $35 copayment for the PT services. The PT services fall 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 reduce the copayment for physical 
therapy (PT) services provided on December 14, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
December 13, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you did not go to the ER for an 
exam, only a CT scan. You say that you feel you should not have to pay the ER copayment. The Plan denied 
your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for each emergency room visit.  
 
You have been asked to pay a $90 copayment for the ER visit. Please note the copayment applies regardless of 
the visit reason. The ER visit falls within the Emergency Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for an emergency room (ER) visit provided on December 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the 
cervical spine provided on December 14, 2021. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI) of the cervical spine. You 
say that you want the hospital to cover the bill as it was their doctor's fault that made you do the MRI. 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 $250 
copayment per day for other Medicare-covered diagnostic radiology services that are not ultrasounds. 
  
 You have been asked to pay a $250 copayment for a magnetic resonance imaging (MRI) of the cervical spine. 
A magnetic resonance imaging (MRI) of the cervical spine 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 
magnetic resonance imaging (MRI) of the cervical spine provided on December 14, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound on October 06, 2021. 
 
You asked the Plan to waive the copayment for ultrasound. You say that the plan did not pay anything for the 
ultrasound your doctor prescribed. The Plan denied your request. The Plan says the copayment 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 $155 
copayment for Medicare-covered radiological diagnostic services.  
 
 
  You have been asked to pay $144.70, which is less than the standard $155 copayment for an ultrasound. The 
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 the ultrasound on October 06, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit for physician's services to be provided by 
the requested out-of-network provider. 
 
You asked the Plan to pre-approve an office visit for physician's services to be provided by the requested out-
of-network provider. You say that you have been having issues with your vision and have not been able to 
drive due to this issue, which has greatly impacted your daily living skills. You say that you have been seeing 
several neurologists and ophthalmologists and optometrist and all have suggested vision therapy. The Plan 
denied your request. The Plan says if you need medical care that Medicare requires our Plan to cover and 
providers in our network cannot provide this care, you can get this care from an out-of-network provider. In 
this situation, we will cover these services as if you got the care from a network provider. If you do not have a 
prior authorization before you receive services from an out-of-network provider, you may have to pay 
for these services yourself. There are in-network provider that can provide the care you have requested. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office 
visit for physician's services to be provided by the requested out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the electrocardiogram on November 18, 
2021. 
 
You asked the Plan to waive the deductible for electrocardiogram. You say that you were billed for your once-
a-year annual checkup which should be free. The Plan denied your request. The Plan says there is a $290 in- 
and out-of-network deductible which applies to certain items and services. 
 
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 $290 in- and out-of-network deductible which applies to other 
outpatient diagnostic test  non-radiological diagnostic services.  
 
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 the $290 deductible applies to diagnostic tests. This cost sharing is a contractual 
obligation that had not been met at the time electrocardiogram was received on November 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 2, 
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 January 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a transthoracic echocardiography provided 
on November 19, 2021. 
 
You asked the Plan to waive the copayment for a transthoracic echocardiography. You say that you had a 
multiple number of tests and they said they had been all preapproved. You also say you even asked before the 
tests were done and they said they had all been preapproved. 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 $155 
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a 
physician's office or at a free-standing facility (such as a radiology center or medical clinic).  
 
You have been asked to pay a $155 copayment for a transthoracic echocardiography. A transthoracic 
echocardiography falls within the outpatient diagnostic tests and therapeutic services and supplies benefit 
category. Although this is a preapproved, covered benefit, there are still cost sharing responsibilities for the 
enrollee. 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 transthoracic echocardiography provided on 
November 19, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a transthoracic echocardiogram (TTE) with 
Doppler provided on November 9, 2021. 
 
You asked the Plan to waive the copayment for the TTE with doppler. You say that the Evidence of Coverage 
does not describe the definition for outpatient hospital services. 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 $50 
copayment for services performed in an outpatient hospital facility, including X-rays and other radiology 
services.  
 You have been asked to pay a $50 copayment for the TTE with doppler. The TTE with doppler is a radiological 
test that falls within the Outpatient Hospital 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 a transthoracic echocardiogram (TTE) with Doppler provided on November 9, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a nuclear medicine study of the heart 
vessels provided on January 12, 2022. 
 
You asked the Plan to waive the copayment for a nuclear medicine study. You say that there should be a $0 
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 $250 
copayment for diagnostic radiology services, including single-photon emission computerized tomography 
(SPECT) at an outpatient hospital.  
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$250 copayment for a nuclear medicine study. A nuclear medicine study 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 study of the heart vessels provided on January 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, a routine electrocardiogram (ECG) and a 
routine venipuncture provided on December 7, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit, a routine electrocardiogram (ECG) and a routine venipuncture. 
You say that the claim was denied incorrectly as this provider is a participating contracted provider and no 
referral is needed for Medicare plans. The Plan denied your request. The Plan says this provider is not a 
network provider with the Plan, and they have also determined that these services are not urgent or emergent, 
nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit, a routine electrocardiogram (ECG) 
and a routine venipuncture provided on December 7, 2021, 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 an ophthalmology specialist office visit 
provided on January 24, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you were scheduled for a 
refraction visit. You also say that the doctor did not address your issues on the first office visit and were just 
scheduled for a third 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 $50 
copayment for an in-network specialist office visit.  
 
 The record shows you had a specialist office visit on January 24, 2022. You have been asked to pay a $50 
copayment for a specialist office visit. A 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 
an ophthalmology specialist office visit provided on January 24, 2022.  
 
Your complaint about being scheduled for a refraction visit and the doctor not addressing issues on the first 
office visit 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.