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

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of a 
lower extremity provided on January 21, 2022. 
 
You asked the Plan to waive the copayment for the MRI. You say that you were not aware of the copayment. 
You say the provider did not inform you either. 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 $175 
copayment for outpatient hi-tech diagnostics, such as MRI's.  
 
You have been asked to pay a $175 copayment for the MRI. The MRI 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 a lower extremity provided on January 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Panniculectomy, Mastopexy, and Breast 
Augmentation (15830, 19316, and 19325). 
 
You asked the Plan to pre-approve a Panniculectomy, Mastopexy, and Breast Augmentation. You say that the 
requested Panniculectomy, Mastopexy, and Breast Augmentation are medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for the requested Panniculectomy, Mastopexy, 
and Breast Augmentation (15830, 19316, and 19325).  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 pre-approve a Panniculectomy, Mastopexy, and 
Breast Augmentation. Our reviewer says that the enrollee does not meet criteria for the requested 
Panniculectomy, Mastopexy, and Breast Augmentation (15830, 19316, and 19325). Our physician reviewer 
found the record indicates that the enrollee had weight loss after bariatric surgery in 2017. The record indicates 
the absence of rashes or intertrigo. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria 
are not satisfied.  The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Panniculectomy, Mastopexy, and Breast Augmentation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Panniculectomy, Mastopexy, and Breast 
Augmentation (15830, 19316, and 19325).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on January 1, 
2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you are appealing the 
copayment amount. You say that you cannot afford to pay this bill. The Plan denied your request. The Plan 
says you have been charged the correct copayment 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 $440 
copayment for each Medicare-covered one-way trip by ground ambulance. Copayment is not waived if 
admitted.  
 
 
 
 You have been asked to pay a $440 copayment for ambulance transport. The ambulance transport 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 
transport provided on January 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on January 17, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for podiatry services. You say that you would like to appeal the denial of the claim. 
The Plan denied your request. The Plan says the provider is out-of-network and authorization is required prior 
to an out-of-network visit. 
 
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 podiatry services provided on January 17, 2022 by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 23, 
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 services were not reported correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. 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 laboratory services provided to the enrollee on April 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Novolog Flexpen for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
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 pre-approve the Novolog Flexpen for the 
enrollee.  
 
Benefits for this drug 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services provided on January 13, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the imaging services. You say that you were never told you needed a referral to 
go to this provider. The Plan denied your request. The Plan says the rendering provider is an OON 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 the imaging services provided on January 13, 
2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on February 8, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that you were not aware of the requirement of obtaining a 
prior authorization, specifically for this member's plan type at the time of rendering services. The Plan denied 
your request. The Plan says the rendering provider is a non-participating provider and the referring provider 
involved in these services is a non-participating provider with the Plan. The Plan also says that they did not 
authorize any services for either the rendering or the referring provider. 
 
 
 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 drug testing provided on February 8, 2022, 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 Urgent Care services provided on 
December 28, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to waive the copayment for Urgent Care services. You say that you would like to appeal the 
cost share. 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 a $65 
copayment for Urgent Care services.  
 
You have been asked to pay a $65 copayment for Urgent Care services. Urgent Care services falls within the 
Urgently needed 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 Urgent Care 
services provided on December 28, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for skin debridement (code 11042) provided 
on January 26, 2022, and February 15, 2022.  
 
You asked the Plan to reduce the copayments for skin debridement. You say that you should only be 
responsible for a $25 copayment for a specialist office visit. 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 outpatient surgery at an outpatient hospital.  
 
The record shows skin debridement code 11042 is considered a surgical procedure. You have been asked to 
pay a $250 copayment for each skin debridement on January 26, 2022, and February 15, 2022. Skin debridement 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 reduce the copayments for 
skin debridement (code 11042) provided on January 26, 2022, and February 15, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on January 26, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that an authorization should not be required, and 
you like the claim reprocessed for payment. The Plan denied your request. The Plan says the rendering provider 
is an OON provider and there was no referral from an in-network provider or an approved authorization. Also, 
the service rendered was not urgent or emergent. 
 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 home health visit provided on January 26, 2022, 
by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
from October 1, 2021, to October 8, 2021. 
 
You asked the Plan to waive the copayment for the SNF care. You say that you should not be responsible for 
the charges due to the lack of care received. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $0 per 
day for days 1-20 and $184 per day for days 21-100 for each benefit period. 
 
 
 Dates of Service Benefit Period Days Copayment 
August 2, 2021  August 11, 2021 1-10 $0/day 
September 22, 2021  October 1, 2021 11-20 $0/day 
October 2, 2021  October 8, 2021 21-27 $184/day 
Total:  $1,288 
 
You have been asked to pay $184 per day for days 21-27 of the SNF care, for a total of $1,288. The SNF care 
falls within the Skilled Nursing Facility (SNF) Care benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for skilled nursing facility (SNF) care provided from October 1, 2021, to October 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory service provided on February 
24, 2022 
 
You asked the Plan to waive the copayment for the laboratory service. You say that you were not aware that the 
lab copayment changed from $5 to $20. The Plan denied your request. The Plan says you have been charged 
the correct copayment 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 $0 
copayment for monitoring or routine Medicare-covered lab services including, but not limited to A1C, 
cholesterol/lipid panel screenings and complete blood count and a $20 copayment for all other Medicare-
covered lab services.  
 You have been asked to pay $16.07 which is less than the standard $20 copayment. The laboratory service 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 laboratory service provided on February 24, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a primary care physician (PCP) office visit 
provided from January 6, 2021, to December 21, 2021.  
 
You asked the Plan to waive the copayment for a PCP office visit. You say that you have been getting B12 
shots since September 2020 and have never been charged until 2021. 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 $10 copayment for a primary care physician office visit. The Plan contract also says that for the administration of a 
drug you will pay the cost sharing that applies to primary care provider services. 
 
The record shows these claims were approved, and you have a cost sharing amount. You have been asked to 
pay a $10 copayment for each PCP office visit from January 6, 2021, to December 21, 2021. You have been 
asked to pay a total of $80 ($10 copayment x 8 visits = $80). A PCP office visit falls 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 a primary care physician (PCP) office visit provided from January 6, 2021, to 
December 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 18, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 laboratory services provided on February 18, 2022 
by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy with polyp removal 
performed on February 10, 2022. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that you were not aware of the 
copayment at the time of the procedure. 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 $295 
copayment for surgery or services provided at an ambulatory surgical center.  
 
The record shows that you had polyps removed during the procedure. This tissue removal makes the procedure 
diagnostic in nature. Therefore, you have been asked to pay a $295 copayment for the colonoscopy.  The colonoscopy 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 colonoscopy with polyp removal performed on February 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthetic agent(s) injection and/or steroid provided on 
February 28, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for anesthetic agent(s) injection and/or steroid. You say that this claim denied as no 
prior authorization obtain, and you apologize for not obtaining a prior authorization. The Plan denied your 
request. The Plan says this provider is non-participating with the Plan. The Plan also says that the member will 
be held harmless as the non-participating provider did not follow the Plan's rules to request authorization for 
out-of-network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for anesthetic agent(s) injection and/or steroid 
provided on February 28, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the lab services received on January 31, 
2022. 
 
You asked the Plan to waive the copayment for the lab services. You say that the lab copay should be included 
with your annual physical. The Plan denied your request. The Plan says the copayment was 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 $10 per 
day for other Medicare-covered laboratory tests that are not FIT tests.  
 
You have been asked to pay $10 for the lab services. The 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 the lab services received on January 31, 2022.