Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the copayment for wound care services performed 
on March 4, 2022. 
 
You asked the Plan to waive or reduce the copayment for the wound care. You say that the charges are too 
much for the services provided. 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 $475 
copayment for each outpatient hospital visit.  
 
You have been asked to pay a total of $341.89, which is less than the $475 copayment for the wound care. The 
wound care 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 or reduce the 
copayment for wound care services performed on March 4, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the copayment for ambulance transportation 
provided on January 14, 2022. 
 
You asked the Plan to waive or reduce the copayment for the ambulance transportation. You say that you did 
not want to take an ambulance and cannot afford the 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 $350 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $350 copayment for the ambulance transportation. The ambulance transportation 
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 or reduce the 
copayment for ambulance transportation provided on January 14, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient surgery and office visit on 
March 29, 2022. 
 
You asked the Plan to waive the copayments for outpatient surgery and office visit. You say that when you 
made the appointment for your colonoscopy you were told it was covered with the plan and was not told that 
there would be a $350 copay due to your recent illness. 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 $350 
copayment for each outpatient surgical service. We cover medically necessary services you get in the 
outpatient department of a hospital for diagnosis or treatment of an illness or injury. Covered services include 
but are not limited to: Services in an emergency department or outpatient clinic, such as observation services or 
outpatient surgery. You must pay a $40 copayment for each Medicare-covered specialist visit. Covered 
services include consultation, diagnosis, and treatment by a specialist. $350 + $40 = $390. Therefore, results in 
the total cost sharing amount of $390. 
 
You have been asked to pay a $350 copayment for outpatient surgery and an $40 copayment for office visit. 
Outpatient surgery and office visit falls within the Outpatient hospital services and 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 copayments 
for outpatient surgery and office visit on March 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Power Wheelchair provided on February 
27, 2022. 
 
You asked the Plan to waive the coinsurance for a Power Wheelchair. You say that you were unaware of this 
cost, and if you had known you would not have gotten the item as you cannot afford this cost. The Plan denied 
your request. The Plan says the coinsurance 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 10% 
coinsurance for durable medical equipment (DME) and related supplies. The allowed amount of this item is 
$21,052.10 resulting in a coinsurance amount of $2,105.21 ($21,052.10 x 10% = $2,105.21). 
 
You have been asked to pay a $2,105.21 coinsurance for a Power Wheelchair. A Power Wheelchair falls within 
the Durable Medical Equipment (DME) and Related Supplies benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan.  This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the coinsurance for a Power Wheelchair provided on February 27, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility (SNF) stay 
provided from February 21, 2022, to March 31, 2022. 
 
You asked the Plan to waive the copayment for the SNF stay. You say that at no time did anyone verbally tell 
you that there would be a copay for the additional days. The Plan denied your request. The Plan says the 
copayment amount 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 enrollees pay no 
copayment for days 1-20 at a Medicare-certified facility. The Plan contract also says that enrollees must pay a 
$140 copayment per day for days 21-100 at a Medicare-certified facility.  
 
 
  You have been asked to pay $2,520 ($140 X 18 days) for the SNF stay. The SNF 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 (SNF) stay provided from February 21, 2022, to March 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a catheter insertion procedure performed on 
January 28, 2022. 
 
You asked the Plan to waive the copayment for the catheter insertion. You say that the insertion was not done 
properly and needed to be redone at a later date. 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 $200 
copayment for each visit to an outpatient hospital facility.  
 
You have been asked to pay a $200 copayment for the catheter insertion. The catheter insertion 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 catheter insertion 
procedure performed on January 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a sacroiliac joint injection performed on 
January 27, 2022. 
 
You asked the Plan to reduce the copayment for the injection. You say that you were not aware of the higher 
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 $200 
copayment for each ambulatory surgical center visit.  
 
You have been asked to pay a $200 copayment for the injection. The injection 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 copayment for a sacroiliac joint injection performed on 
January 27, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency department visit provided 
on January 12, 2022. 
 
You asked the Plan to waive the copayment for the emergency department services. You say that you should 
not have to pay the copay because you were never seen by a doctor. 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 $90 
copayment for each emergency room visit.  
 
You have been asked to pay a $90 copayment for an emergency room visit. Emergency department 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 
the emergency department visit provided on January 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on February 
16, 2022. 
 
You asked the Plan to waive the copayment for the lab services. You say that you do not understand why 
sometimes you are charged and sometimes you are not. 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 $35 
copayment for lab services at an outpatient hospital.  
 
You have been asked to pay a total of $28.26, which is less than the $35 copayment 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 laboratory services provided on February 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit including a diagnostic 
test provided from March 15, 2022, to March 16, 2022. 
 
You asked the Plan to waive the copayment for an urgent care visit including a diagnostic test. You say that 
you were told the urgent care fee would be waived if you went to the ED. You feel you were misled. The Plan 
denied your request. The Plan says the copayments applied were 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 $30 
copayment for urgently needed services.  
 
You have been asked to pay a $38.11 copayment for an urgent care visit and for a diagnostic test ($30 + $8.11 
= $38.11). An urgent care visit including a diagnostic test fall 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 an urgent care visit including a diagnostic test 
provided from March 15, 2022, to March 16, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the extremity study, an ultrasound study of 
arm and leg arteries provided on March 30, 2022. 
 
You asked the Plan to waive the copayment for the extremity study. You say that this is part of a post-surgical 
procedure for a surgery you had in February 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 $120 
copayment for radiological diagnostic services.  
 
You have been asked to pay the allowed amount of $109.66, which is less than the $120 copayment for 
radiological diagnostic services. An extremity study 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 extremity study, an ultrasound study of arm and leg arteries provided on March 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2790) for tooth #31 provided by an out-of-
network provider on April 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were having pain in your tooth. You said 
that you needed this crown fixed. The Plan denied your request. The Plan says your benefit for the requested 
item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 8, 2020. 
Therefore, we decided that the Plan does not have to pay for a crown (D2790) for tooth #31 provided by an 
out-of-network provider on April 18, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99218 billed for date of service September 8, 2021. 
 
You asked the Plan to pay for procedure code 99218. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says that this procedure has been billed and allowed the 
maximum number of times allowed by the Plan's payment policy. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's sole rationale for denial is that this procedure had already 
been billed and allowed the maximum number of times.  However, the Plan has failed to provide any 
documentation showing that this service had already been paid and how many units of it had been allowed.  
The burden is on the Plan to prove that its denial is correct. By not providing any evidence showing that this 
code had already been paid, the Plan has failed to meet that burden. Therefore, we decided that the Plan has to 
pay for procedure code 99218 billed for date of service September 8, 2021.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound of the eye provided on  
March 24, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you are on a fixed income, and you 
feel this copayment should be covered. The Plan denied your request. The Plan says the copayment applied was 
correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment per day for a Medicare-covered ultrasound.  
 
You have been asked to pay $79.30 for an ultrasound, which is less than your $100 copayment. An ultrasound 
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 an ultrasound of the eye provided on March 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on December 6, 2021. 
 
You asked the Plan to pay for the dental services. You say that you believe these services should be covered 
since they were rendered as a result of an accident. The Plan denied your request. The Plan says you do not 
have dental insurance coverage. The Plan also says that non-routine dental care is not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. The records show that these services were provided due to a fall you had. Therefore, we 
decided that the Plan does not have to pay for the dental services provided on December 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) rendered by 
the out-of-network (OON) provider on February 23, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the chiropractic manipulative treatment (98941) rendered by the out-of-network 
(OON) provider on February 23, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
March 18, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you did not have a 
choice regarding transportation. 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 $350 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $350 copayment for the ambulance transportation. The ambulance transportation 
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 transportation provided on March 18, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
January 14, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you cannot afford 
the high 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 $325 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $325 copayment for the ambulance transportation. The ambulance transportation 
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 transportation provided on January 14, 2022.