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

 
We decided that the Plan does not have to waive the copayment for an ambulance service provided on February 
11, 2022. 
 
You asked the Plan to waive the copayment for an ambulance service. You say that the ambulance team did not 
let you drive home. The Plan denied your request. The Plan says this cost sharing was charged 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 $300 
copayment for ambulance services. 
 
You have been asked to pay a $300 copayment for an ambulance service. This item/service 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 an ambulance 
service provided on February 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the dialysis services provided on March 
18, 2022, to March 30, 2022. 
 
You asked the Plan to waive the coinsurance for the dialysis services. You say that you cannot afford these 
weekly charges. The Plan denied your request. The Plan says this cost sharing was charged 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 outpatient dialysis treatments. 
 
You have been asked to pay 20% coinsurance for the dialysis services. This item/service falls within the 
outpatient dialysis treatments 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. The file shows a total of 6 dialysis treatments from March 18, 2022, to March 30, 2022. 
The allowed amount for each treatment is $294.00, and the 20% coinsurance applied is $58.80. The total for all 
6 visits is $352.80. Therefore, we decided that the Plan does not have to waive the coinsurance for the dialysis 
services provided on March 18, 2022, to March 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical services to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the service is necessary. The Plan 
denied your request. The Plan says there is an in-network provider that can perform the services the enrollee 
needs. 
 
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 
the surgical services to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on April 11, 2022. 
 
You asked the Plan to pay for foot orthotics. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on April 11, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the negative pressure wound therapy 
services provided from August 3, 2021, to September 13, 2021. 
 
You asked the Plan to waive the cost share for the negative pressure wound therapy services. You say that you 
are appealing this cost-sharing. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a 20% coinsurance for durable medical equipment. 
    
 
The enrollee has been asked to pay a 20% coinsurance for the negative pressure wound therapy services for a 
total of $767.34. The negative pressure wound therapy services fall within the Durable Medical Equipment 
(DME) and Related Supplies 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 cost share for 
the negative pressure wound therapy services provided from August 3, 2021, to September 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory testing provided on March 9, 
2022. 
 
You asked the Plan to waive the copayment for the laboratory testing. You say that you have had these tests 
done before without a copayment. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5 
copayment per day for laboratory tests.  
 
You have been asked to pay a $5 copayment for the laboratory testing. This item/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 the laboratory testing provided on March 9, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging, 
tomographic (SPECT) test provided on March 17, 2022. 
 
You asked the Plan to waive the copayment for the myocardial perfusion imaging, tomographic (SPECT) test. 
You say that you were informed that you should not be billed. The Plan denied your request. The Plan says this 
cost sharing was charged 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 $200 
copayment for diagnostic radiology services other than x-rays, mammograms, and ultrasounds. 
 
You have been asked to pay a $200 copayment for the myocardial perfusion imaging, tomographic (SPECT) 
test. This item/service falls within the diagnostic radiology services other than x-rays, mammograms, and 
ultrasounds 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 myocardial perfusion 
imaging, tomographic (SPECT) test provided on March 17, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the duplex scan (ultrasound) of extracranial 
arteries provided on May 16, 2022. 
 
You asked the Plan to waive the copayment for the duplex scan (ultrasound) of extracranial arteries. You say 
that you believe this should be covered as a preventive test. The Plan denied your request. The Plan says this 
cost sharing was charged 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 
$107.84 copayment for diagnostic tests and procedures in an outpatient facility. 
 
You have been asked to pay a $107.84 copayment for the duplex scan (ultrasound) of extracranial arteries. This 
item/service falls within the diagnostic tests and procedures in an outpatient facility 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. The allowed amount for 
the duplex scan is $107.84. Since this is less than the $175 copayment per the EOC, you are only responsible 
for the lesser amount. Therefore, we decided that the Plan does not have to waive the copayment for the duplex 
scan (ultrasound) of extracranial arteries provided on May 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a biopsy provided on March 17, 2022. 
 
You asked the Plan to waive the deductible for a biopsy. You say that the Plan did not cover the $44.44. The 
Plan denied your request. The Plan says this cost sharing was charged 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 $500 
deductible for outpatient diagnostic tests and therapeutic services and supplies. You already paid $455.56 of the 
$500 deductible for the year. You had a remaining $44.44, which was applied to this service ($500.00 - 
$455.56 = $44.44). 
 
You have been asked to pay a $44..44 deductible for a biopsy. This item/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 
deductible for a biopsy provided on March 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-rays on June 20, 2022. 
 
You asked the Plan to waive the copayment for x-rays. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged 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 35% 
coinsurance for out-of-network diagnostic procedures and tests. Covered services include but are not limited to 
other outpatient diagnostic tests. The provider billed in the amount of $182.05 and the allowed amount is 
$69.86. $69.86 x 35% = $24.45. Therefore, results in the total cost sharing amount of $24.45. 
 
You have been asked to pay 35% coinsurance for x-rays. This item/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 x-rays on June 20, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the duplex scan (ultrasound) of extracranial 
arteries provided on May 27, 2022. 
 
You asked the Plan to waive the copayment for the duplex scan (ultrasound) of extracranial arteries. You say 
that you were previously informed that there was no copayment for the test. The Plan denied your request. The 
Plan says this cost sharing was charged 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 diagnostic procedures and tests, including ultrasounds. 
 
You have been asked to pay a $125 copayment for the duplex scan (ultrasound) of extracranial arteries. This 
item/service falls within the diagnostic procedures and tests, including ultrasounds 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 duplex scan (ultrasound) of extracranial arteries 
provided on May 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound on May 09, 2022. 
 
You asked the Plan to waive the copayment for 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110 
copayment for Medicare-covered radiological diagnostic services, not including X-rays, performed in a 
physicians office or at a free-standing facility (such as radiology center or medical clinic). Covered services 
include but are not limited to other outpatient diagnostic tests  radiological diagnostic services, not including 
x-rays. The provider billed in the amount of $294 and the allowed amount is $82.22. This is less than the 
copayment amount. Therefore, results in the total cost sharing amount $82.22. 
 
 
 You have been asked to pay a $82.22 copayment, which is less than the copayment for ultrasound. Ultrasounds 
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 ultrasound on May 09, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for ambulance on May 29, 2022, to May 30, 
2022. 
 
You asked the Plan to waive the copayments for ambulance. 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 $325 
copayment per one-way trip for Medicare-covered ambulance services. Covered ambulance services include 
fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that can provide 
care if they are furnished to a member whose medical condition is such that other means of transportation could 
endanger the persons health or if authorized by the plan. There were 2 dates of services. $325 x 2 = $650. 
Therefore, results in total cost sharing amount of $650. 
 
 You have been asked to pay a $325 copayment for each ambulance. Ambulance 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 copayments for ambulance on May 29, 
2022, to May 30, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on March 23, 
2022. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that you were not told you would have 
such a large copayment, and it will cause a hardship. The Plan denied your request. The Plan says this cost 
sharing was charged 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 $275 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $275 copayment for a colonoscopy. This item/service 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 provided on March 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 10, 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 of the 
denied 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 laboratory services provided on May 10, 2022, by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hysteroscopy provided on May 20, 
2022. 
 
You asked the Plan to waive the copayment for the hysteroscopy. You say that you dont remember paying a 
copayment for this procedure before. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $300 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $300 copayment for the hysteroscopy. This item/service 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 the hysteroscopy provided on 
May 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a hip procedure provided from April 20, 
2022, to April 21, 2022. 
 
You asked the Plan to waive the coinsurance for a hip procedure. You say that you should not have a 
coinsurance if you were admitted to the hospital. 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 25% 
coinsurance for outpatient hospital services. The allowed amount of this surgery is $12,992.89 resulting in a 
$3,248.22 coinsurance ($12,992.89 x 25% = $3,248.22). 
 
You have been asked to pay a $3,248.22 coinsurance for a hip procedure. A hip procedure 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 coinsurance for a hip procedure provided from April 20, 2022, to April 21, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Part B drugs on February 09, 2022. 
 
You asked the Plan to waive the coinsurance for Part B drugs. 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 Part B Chemotherapy drugs and other Part B drugs. These drugs are covered 
under Part B of Original Medicare. Members of our plan receive coverage for these drugs through our plan. 
Covered drugs include drugs that usually arent self-administered by the patient and are injected or infused 
while you are getting physician, hospital outpatient, or ambulatory surgical center services. The provider billed 
in the amount of $38,344.25 and the allowed amount is $5,693.10. $5,693.10 x 20% = $1,138.62 The provider 
also billed in the amount of $15,151 and the allowed amount is $2,287.27. $2,287.27 x 20% = $457.45. 
$1,138.62 + $457.45 = $1,596.07. Therefore, results in the total costs sharing amount of $1,596.07. 
 You have been asked to pay a 20% coinsurance for Part B drugs. Part B drugs 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 Part B drugs on 
February 09, 2022.