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

 
We decided that the Plan does not have to waive the copayment for emergency room visit on October 21, 2021. 
 
You asked the Plan to waive the copayment for emergency room visit. You say that you are on a limited 
income and cannot afford to pay this bill. The Plan denied your request. The Plan says coinsurance 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 $90 
copayment for each Medicare-covered emergency room visits.  
 
  You have been asked to pay $90 copayment for emergency room visit. The emergency room 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 emergency 
room visit on October 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Skilled Nursing Facility services provided on November 8, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Skilled Nursing Facility services. You say that the rendering physician, provider, 
is a hospitalist physician with the group and depends upon the hospital staff to verify eligibility and to obtain 
the proper authorization from the patients insurance company. I ask you not to penalize our doctor for the 
hospital staffs failure in taking the proper steps to obtain authorization for these services. The Plan denied your 
request. The Plan says the provider is out-of-network and it was determined these services can be received in-
network. 
 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 Skilled Nursing Facility services provided on 
November 8, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (70450) provided January 20, 2022. 
 
You asked the Plan to pay for the radiology services. You say that the radiology services were medically 
necessary. The Plan denied your request. The Plan says the codes billed share a bundled relationship. 
 
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 radiology services (70450) provided January 20, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ER visit provided on November 24, 
2021. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you shouldn't have to pay the ER 
copay because it was related to the surgery you had the day before. 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 a $90 
copayment for emergency care. Cost-sharing is waived if you are admitted to the hospital within 24 hours.  
 
You have been asked to pay $90 for the ER visit. An 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 the ER visit provided on November 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 23, 2020. 
 
You asked the Plan to pay for an office visit. The Plan denied your request. The Plan says a corrected claim 
must be receive within one year (12 months) from the processed date of the original claim submission. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for an office visit was not filed until December 23, 2021. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for an office visit provided on November 23, 2020.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to reduce the copayment for the PT services, however they do not have to fully 
waive the copayment.  
 
You asked the Plan to waive the copayment for the PT services. You say that you were not aware of a separate 
charge for physical therapy. The Plan says that you have been charged the correct cost sharing amount. 
 
 We decided that the Plan has to reduce the copayment for the PT services. 
 
You have been asked to pay a total of $104.52 for four separate PT services received on September 2, 2021. 
However, the Plan contract does not clearly define if the copayment applies to each billed code, or if there is 
only one copayment per date of service. For this reason, we must find partially in your favor. Therefore, we 
decided that the Plan has to reduce the copayment for the PT services from $104.52 to $40. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Emergency Room Services on September 
19, 2021. 
 
You asked the Plan to waive the copayment for Emergency Room Services. You say that you do not have 
money for this. The Plan denied your request. The Plan says the cost share 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 $90 
copayment for Emergency Room Services.  
 
You have been asked to pay a $90 copayment for Emergency Room Services. Emergency Room Services 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 Emergency 
Room Services on September 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a diagnostic eye exam provided on January 
18, 2022. 
 
You asked the Plan to waive the deductible for the eye exam. You say that under your retirement you are 
entitled to one routine exam per year. The Plan denied your request. The Plan says the correct amount was 
applied to your deductible. 
 
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 $150 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Vision Services benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $150 
deductible which applies to certain items and services. The record shows you were seen specifically for 
pseudophakia OU, which makes the exam diagnostic in nature. This cost sharing is a contractual obligation that 
had not been met at the time the eye exam was received on January 18, 2022. Therefore, we decided that the 
Plan does not have to waive the deductible for a diagnostic eye exam provided on January 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the injection provided on November 11, 
2021. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you would like this injection 
covered. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for each Medicare-covered Part B drug.  
 
  You have been asked to pay $200.88 (allowed amount=$1,004.40 x 20%) for the injection. An 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 the 
coinsurance for the injection (a Medicare Part B drug) provided on November 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Vision Care provided on February 15, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Vision Care. You say that you have been told numerous times that a referral is 
not needed. Therefore, you are requesting that the plan reconsider payment. The Plan denied your request. The 
Plan says the provider is out-of-network and it was determined these services were 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 Vision Care provided on February 15, 2022 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 the inpatient hospital stay provided from 
October 28, 2021, to October 30, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you are on a fixed 
income and cannot afford to pay this bill. 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 for each 
Medicare-covered hospital stay, for days 1-6, a $295 copayment per day and for days 7-90 a $0 copayment per 
day.  You have been asked to pay a total of $590 ($295 copay x 2 days) for the inpatient hospital stay. An inpatient 
hospital stay 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 the inpatient hospital stay provided from October 28, 2021, to October 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 1, 2022, by an 
OON provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration for the 
claim based on medical necessity. 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 the laboratory services provided on February 1, 
2022, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory work provided on December 17, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory work. You say that you have not been sent a bill tp pay, but you 
cannot afford to take this bill. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 laboratory work at issue in this appeal. The Plan did not pre-approve the 
laboratory work. We found no exception that would require the Plan to pay for the laboratory work. Therefore, 
we decided that the Plan does not have to pay for the laboratory work provided on December 17, 2021, 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 November 29, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that you would like to point out 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 the rendering 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 November 29, 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 coinsurance for an injection provided on December 15, 
2021. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you were not told a coinsurance 
would be charged. The Plan denied your request. The Plan says the proper 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 that are administered by a provider. The total allowed amount for the injection 
was $1,398.54 and a coinsurance charge of $279.71 ($1,398.54 total amount x 20% coinsurance). 
 
  You have been asked to pay a $279.71 coinsurance for the injection. 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 the coinsurance for an 
injection provided on December 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre System and associated supplies. 
 
You asked the Plan to pre-approve a Freestyle Libre System and associated supplies. You say that the services 
are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre System and associated supplies have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Freestyle Libre System and associated supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit and radiation therapy to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit and radiation therapy to be provided by an OON provider. 
You say that the services are necessary. The Plan denied your request. The Plan says there are in-network 
providers that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit and radiation therapy to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services rendered by the out-of-network 
(OON) provider on August 18, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the radiology services rendered by the out-of-network (OON) provider on  
August 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 22, 2021. 
 
You asked the Plan to pay for the lab services. You say that you do not have a contract with the dialysis 
facility. The Plan denied your request. The Plan says these labs are not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
lab services provided on October 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visits provided on August 
24, 2021, and September 3, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visits. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $75 
copayment for Physician/Practitioner services, including doctors office visits.  
 
 
  You have been asked to pay a $150 copayment for two specialist office visits. The record indicates that the 
rendering provider is out-of-network with the plan 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 
specialist office visits provided on August 24, 2021, and September 3, 2021.