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

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 8, 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 May 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab test on April 12, 2022. 
 
You asked the Plan to waive the copayment for lab test. 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 $10 
copayment per day for other Medicare-covered laboratory tests that are not FIT tests. Covered services include 
but are not limited to laboratory tests. 
 
You have been asked to pay a $10 copayment for lab test. Lab tests 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 test on April 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiation therapy provided on March 8, 
2022. 
 
You asked the Plan to waive the copayment for radiation therapy. You say that you were unaware that you 
would have a copayment for the services and cannot afford to pay them. 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 $60 
copayment for Medicare-covered therapeutic radiology services.  
 
 
  You have been asked to pay a $60 copayment for radiation therapy. Radiation therapy falls within the 
Outpatient Diagnostic Test 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 radiation therapy provided on March 8, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient procedure provided on 
January 13, 2022. 
 
You asked the Plan to waive the copayment for an outpatient procedure. You say that this was not a procedure 
it was just an injection. The Plan denied your request. The Plan says the copayment that was 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 $325 
copayment for outpatient hospital facility visit.  
 
You have been asked to pay a $325 copayment for an outpatient procedure. an outpatient procedure falls within 
the outpatient hospital facility visit 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 outpatient procedure provided on January 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) on 
April 21, 2022. 
 
You asked the Plan to waive the copayment for MRI. You say that you should not owe because they plan paid 
less than your liability on the claim. 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 $225 
copayment for advanced imaging service (not including x-ray). Advanced imaging (services such as CT, CTA, 
MRI, MRA, nuclear stress test, PET scans, SPECT).  
 
 
 
 
 You have been asked to pay a $225 copayment for MRI. 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 
magnetic resonance imaging (MRI) on April 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 17, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 
 The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 the laboratory services related to end-stage renal disease (ESRD) provided on 
February 17, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility stay provided from 
December 23, 2021, to December 31, 2021. 
 
You asked the Plan to waive the copayment for a skilled nursing facility stay. You say that you do not 
understand why this amount is so high or why you even have a copayment. 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 $184 a 
day for days 21 to 45 for Skilled Nursing Facility (SNF) Care ($184 x 3 days = $552).  
 
You have been asked to pay $552 for a skilled nursing facility stay. A skilled nursing facility stay 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 a skilled nursing facility stay provided from December 23, 2021, to December 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided from March 27, 
2022, to March 31, 2022. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you should not have this 
copayment and that the plan should cover everything. The Plan denied your request. The Plan says the 
copayment that was 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 $275 per 
day for days 1 to 5 for inpatient hospital care (4 days x $275 per day = $1,100). 
 
You have been asked to pay $1,100 for an inpatient stay. An inpatient 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 an inpatient stay provided from 
March 27, 2022, to March 31, 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 you could have called a 
taxi or something, but the ambulance was ordered for you by the facility. 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 $350 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $350 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for radiation therapy provided from March 16, 
2022, to March 18, 2022. 
 
You asked the Plan to waive the copayments for radiation therapy. You say that  The Plan denied your request. 
The Plan says you were unaware that you would have a copayment for the services and cannot afford to pay 
them. 
 
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 $60 
copayment for Medicare-covered therapeutic radiology services.  
 
 
  You have been asked to pay $180 for radiation therapy ($60 copayment x 3 visits = $180). Radiation therapy 
falls within the Outpatient Diagnostic Test 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 copayments for radiation therapy provided from March 16, 2022, to March 18, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a second ambulance transportation 
provided to the enrollee on April 5, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the enrollee had to 
be taken to a different hospital with a neurologist. You say the enrollee should not have to pay for a second trip. 
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 $325 copayment for each one-way ambulance service.  
 
The enrollee has been asked to pay a $325 copayment for the ambulance transportation. The ambulance 
transportation falls within the Ambulance Services 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 a second ambulance transportation provided to the enrollee on April 5, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiation therapy provided on March 14, 
2022. 
 
You asked the Plan to waive the copayment for radiation therapy. You say that that you were unaware that you 
would have a copayment for the services and cannot afford to pay them. 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 $60 
copayment for Medicare-covered therapeutic radiology services.  
 
 
  You have been asked to pay a $60 copayment for radiation therapy. Radiation therapy falls within the 
Outpatient Diagnostic Test 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 radiation therapy provided on March 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on January 10, 
2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you never requested this visit 
and feel you shouldn't have to pay for the copayment. The Plan denied your request. The Plan says the 
copayment that was 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 $40 
copayment for in-network physician/practitioner services including office visits.  
 
You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the in-network 
Physician/Practitioner Services Including 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 specialist visit provided on January 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for radiation therapy provided from April 20, 
2022, to April 22, 2022. 
 
You asked the Plan to waive the copayments for radiation therapy. You say that you were unaware that you 
would have a copayment for the services and cannot afford to pay them. 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 $60 
copayment for Medicare-covered therapeutic radiology services.  
 
 
  You have been asked to pay $180 for radiation therapy ($60 copayment x 3 visits = $180). Radiation therapy 
falls within the Outpatient Diagnostic Test 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 copayments for radiation therapy provided from April 20, 2022, to April 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiation therapy on February 22, 2022. 
 
You asked the Plan to waive the copayment for radiation therapy. 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 $60 
copayment for therapeutic radiological services.  
 
You have been asked to pay a $60 copayment for radiation therapy. Radiation therapy falls within the 
Diagnostic services, labs and imaging 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 
radiation therapy on February 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided from April 1, 
2022, to April 18, 2022. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you feel you should not have to 
pay this large copayment, as you were in the hospital due to a provider mistake. 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 $250 
copayment for days 1-7 for inpatient hospital care.  
 
You have been asked to pay $1750 copayment for an inpatient stay ($250 x 7 = $1750). An inpatient 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 
an inpatient stay provided from April 1, 2022, to April 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for home ventilator on April 25, 2022. 
 
You asked the Plan to waive the coinsurance for home ventilator. 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 20% 
coinsurance for Medicare-covered items of Durable medical equipment (DME). Covered items include, but are 
not limited to wheelchairs, crutches, powered mattress systems, diabetic supplies, hospital beds ordered by a 
provider for use in the home, I V infusion pumps, speech generating devices, oxygen equipment, nebulizers, 
and walkers. The provider billed in the amount of $4,430.10 and the allowed amount is $886.39. $886.39 x 
20% = $177.28. Therefore, results in the total cost sharing amount of $177.28. 
 
 
 You have been asked to pay a 20% coinsurance for home ventilator. Home ventilators fall 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 home ventilator on April 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiation therapy provided on April 1, 
2022. 
 
You asked the Plan to waive the copayment for radiation therapy. You say that you were unaware that you 
would have a copayment for the services and cannot afford to pay them. 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 $60 
copayment for Medicare-covered therapeutic radiology services.  
 
 
  You have been asked to pay a $60 copayment for radiation therapy. Radiation therapy falls within the 
Outpatient Diagnostic Test 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 radiation therapy provided on April 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a lesion destruction procedure performed 
on May 2, 2022. 
 
You asked the Plan to waive the copayment for the lesion destruction. You say that you only had a spray 
applied. You say there was no surgery performed. 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 $150 
copayment for surgery or services provided at an outpatient hospital.  
 
You have been asked to pay $114.85, which is less than the $150 copayment for the lesion destruction. The 
lesion destruction 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 lesion destruction procedure performed on May 2, 2022.