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

 
We decided that the Plan does not have to waive the copayments for an outpatient procedure provided from 
May 12, 2022, to June 2, 2022. 
 
You asked the Plan to waive the copayments for an outpatient procedure. You say that you were never told 
about your cost share for these procedures. Therefore, you feel you should not have to pay these copayments. 
The Plan denied your request. The Plan says the copayments were applied 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 $350 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers ($350 x 4 dates = $1400).  
 
You have been asked to pay a $1400 copayment for an outpatient procedure. An outpatient procedure 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 copayments for an outpatient procedure provided from May 
12, 2022, to June 2, 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 it was required for you to 
be moved from one facility to the other to continue your care. You should not have to pay. The Plan denied 
your request. The Plan says you were charged this cost sharing 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 $125 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $125 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the ambulance services provided on May 
12, 2022. 
 
You asked the Plan to reduce the copayment for the ambulance services. You say that you were told the 
copayment would only be $125. The Plan denied your request. The Plan says you were charged this cost 
sharing 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 $325 
copayment for each ambulance trip. You had one ambulance trip(s). The Plan charged you $325 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 reduce the copayment for the ambulance services provided on May 12, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for  MRI provided on April 7, 2022. 
 
You asked the Plan to waive the copayment for  MRI. You say that this should be covered. The Plan denied 
your request. The Plan says the copayment applied 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 $225 
copayment for advanced imaging service (not including x-rays).  
 
You have been asked to pay $223.92 which is less than the standard $225 copayment for MRI. MRIs fall 
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 MRI provided on April 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a leg brace provided on April 28, 2022. 
 
You asked the Plan to waive the coinsurance for a leg brace. You say that you were told there would be no 
charge for this. The Plan denied your request. The Plan says the coinsurance applied 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 20% 
coinsurance for DME.  
 
You have been asked to pay $230.88 which is 20% of the allowed amount for a leg brace. The allowed amount 
is $1,154.42(20% x $1,154.42= $230.88). A leg brace 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 a leg brace provided 
on April 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a furosemide injection (procedure code J1940) provided to 
the enrollee on February 9, 2022, and February 10, 2022. 
 
You asked the Plan to pay for the injection. You say that this should be paid for. The Plan denied your request. 
The Plan says there is no separate payment for this code. 
 
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, the CPT Code Manual definition of drug code J1940 is "Injection, furosemide, up to 20 mg." 
 
We find that CPT code J1940 is not supported in the medical record. Specifically, this code has a status 
indicator of "N" which means that it cannot be paid separately. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pay for a furosemide injection (procedure code J1940) provided to the enrollee on February 9, 2022, 
and February 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neurophysiology services (procedure code 95885, 95907, 
95955) provided to the enrollee on March 24, 2022. 
 
You asked the Plan to pay for the services. You say that the attached documents attached support the 
procedures performed and has a description of the services performed. The Plan denied your request. The Plan 
says the records do not support the services billed. 
 
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, the CPT Code Manual definition of the denied codes are: 
 
CPT 95885: 
 
Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve 
conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary 
procedure) 
 CPT 95907: 
 
Nerve conduction studies; 1-2 studies 
 
CPT 95955: 
 
Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery) 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, the enrollee did not 
undergo a nerve conduction study, as defined by the Current Procedural Terminology (CPT) Manual. The 
patient had pedicle screw testing performed during the course of their procedure. However, pedicle screw 
testing is considered an inherent part of electromyography (EMG). and is not coded separately. As such, CPT 
95907 cannot be said to be supported by the records. As a nerve conduction study was not done, the use of CPT 
95885 would not be correct coding. In terms of CPT 95955, the enrollee underwent a two channel EEG. This is 
below the technical threshold set-forth by the American Clinical Neurophysiology Society (ACNS) technical 
standards for performance of EEG. Therefore it cannot be said that the requirements for the CPT code have 
been met. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for neurophysiology services (procedure code 95885, 95907, 95955) provided to the enrollee on 
March 24, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a rollator walker with seat. 
 
You asked the Plan to pre-approve a rollator walker with seat. You say that this walker is necessary for you to 
travel. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
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 specifically being requested 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 rollator walker with seat.
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 4, 2021, to November 21, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that this should be covered. 
The Plan denied your request. The Plan says the copayment applied 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 $295 
copayment each day for days 1 to 5 for Medicare covered hospital care. $0 copayment for additional Medicare-
covered days.  
 
 
 
 You have been asked to pay $1,475 ($295 x 5 days) copayment for inpatient hospital care. Inpatient hospital 
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 4, 2021, to November 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on February 2, 2022, 
to February 3, 2022. 
 
You asked the Plan to waive the coinsurance for an injection. You say that your insurance should cover this. 
The Plan denied your request. The Plan says the coinsurance applied 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 20% 
coinsurance for Medicare Part B chemotherapy drugs, associated administration services and all other 
Medicare Part B drugs.  
 
 
 
 You have been asked to pay $73.88 which is 20% of the allowed amount for an injection. The allowed amount 
is $369.41 (20% x $369.41= $73.88). Injections fall 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 an injection provided on February 2, 2022, to 
February 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for computed tomography (CT scan) and 
ultrasound on March 11, 2022, to March 17, 2022. 
 
You asked the Plan to waive the deductible for CT scan and ultrasound. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says the cost sharing you are being charged is 
correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1000 deductible which applies to Outpatient diagnostic tests and 
therapeutic services and supplies.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $1000 deductible which applies to Outpatient diagnostic tests and 
therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time 
CT scan and ultrasound was received on March 11, 2022, to March 17, 2022. Therefore, we decided that the 
Plan does not have to waive the deductible for computed tomography (CT scan) and ultrasound on March 11, 
2022, to March 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for antigen therapy services provided on May 
17, 2022. 
 
You asked the Plan to waive the copayment for the antigen therapy. You say that the coinsurance continues to 
change. 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 $45 
copayment for each specialist visit.  
 
You have been asked to pay a $45 copayment for the antigen therapy. The antigen therapy 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 antigen therapy services provided on May 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the coinsurance for a drug injection provided on 
March 18, 2022. 
 
You asked the Plan to waive or reduce the coinsurance for the injection. You say that you were only charged 
$14 for these services before. 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 Part B drugs.  
 
You have been asked to pay $30, which is 20% of the allowed amount for the injection ($150 allowed amount 
x 20% coinsurance = $30). The injection 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 or reduce the coinsurance for a drug injection provided on March 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT scan) on March 
11, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for each Medicare-covered diagnostic radiology. Covered services include but are not limited to 
other outpatient diagnostic tests. 
 
You have been asked to pay a $275 copayment for CT scan. CT scans fall 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 
computed tomography (CT scan) on March 11, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for colonoscopy on May 25, 2022. 
 
You asked the Plan to waive the copayment for colonoscopy. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for same-day outpatient surgery in a freestanding Ambulatory Surgical Center. We cover 
medically-necessary services you get in the outpatient department of a hospital for diagnosis or treatment of an 
illness or injury. Covered services include but are not limited to same day outpatient surgery (Includes 
diagnostic scopes such as an endoscopy). 
 
 
 
 
 You have been asked to pay a $250 copayment for colonoscopy. Colonoscopy 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 colonoscopy on May 
25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for inpatient hospital care provided from 
September 20, 2021, to September 24, 2021. 
 
You asked the Plan to waive the coinsurance for the inpatient care. You say that you should not be responsible 
for the charges. 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 inpatient stay.  
 
You have been asked to pay $352.90, which is less than 20% of the allowed amount for the inpatient care 
($24,954.05 allowed amount x 20% coinsurance = $4,990.81). Please note that the amount charged is less due 
to meeting your maximum out-of-pocket (MOOP) expenses for the year. 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 coinsurance for inpatient 
hospital care provided from September 20, 2021, to September 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services on April 06, 2022. 
 
You asked the Plan to waive the copayment for lab services. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $65 
copayment for out-of-network lab services at primary care providers (PCP) office, specialists office and 
urgent care center. Covered services include but are not limited to laboratory tests. The provider billed in the 
amount of $39 and the Plan benefit exclusions is $36. $39 - $36 = $3. This is less than the copayment amount. 
Therefore, results in the total cost sharing amount of $3. 
 
 
 
 
 You have been asked to pay a $3 copayment, which is less than the copayment for lab services. Lab services 
fall 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 lab services on April 06, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an endoscopy provided on April 7, 2022. 
 
You asked the Plan to waive the copayment for an endoscopy. You say that this should have been done while 
you were inpatient, but there was no room to have it done at the time. Therefore, you feel you should not have 
to pay a 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 $250 
copayment for outpatient procedures and services, including, but not limited to, diagnostic and therapeutic 
endoscopy.  
 
You have been asked to pay a $250 copayment for an endoscopy. An endoscopy falls within the Outpatient 
Procedures and Services, Including, But Not Limited To, Diagnostic and Therapeutic Endoscopy 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 endoscopy provided on April 7, 2022.