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

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on May 26, 
2022. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you were only seen for a 
covid test and did not see a provider directly. 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 $45 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $45 copayment for an urgent care visit. 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 an urgent care visit provided on May 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic services (98941) to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the chiropractic services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they are 
non-emergent and can be provided 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 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 
chiropractic services (98941) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diagnostic casts (D0470) and an unspecified removable 
prosthodontic procedure (D5899) provided by  
 
You asked the Plan to pre-approve diagnostic casts and an unspecified removable prosthodontic procedure. 
You say that you need these services in order to get the appropriate denture. The Plan denied your request. The 
Plan says the requested dental services are not covered benefits. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
diagnostic casts (D0470) and an unspecified removable prosthodontic procedure (D5899) provided a 
participating provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not require skilled nursing services with the specialized skill, 
knowledge and judgment of a skilled professional nurse  to safely and effectively provide medically necessary 
and reasonable treatment in a SNF. There is no documentation of  new enteral feedings, complex wound care 
or other SNF nursing need. The patient's  functional level does not require skilled therapy services with the 
specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically 
necessary and reasonable treatment in a SNF. The patient does not require skilled nursing or skilled therapy on 
a daily basis or as a practical matter in a SNF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laparoscopy procedures (43775, 43281) to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the laparoscopy procedures. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they 
are non-emergent and can be provided 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 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 
laparoscopy procedures (43775, 43281) to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the retroperitoneal ultrasound provided on 
May 24, 2022. 
 
You asked the Plan to reduce the copayment for the retroperitoneal ultrasound. You say that you paid less for 
the same service last year. 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 
$114.23 copayment for diagnostic radiology, including magnetic resonance imaging (MRI) and computed 
tomography (CT). 
 
You have been asked to pay a $114.23 copayment for the retroperitoneal ultrasound. This item/service falls 
within the diagnostic radiology, including magnetic resonance imaging (MRI) and computed tomography (CT) 
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 ultrasound is $114.23. Since this amount is less than the $200 copayment per the EOC, you are only responsible for the lesser amount. Therefore, we decided that the Plan does not have to reduce the 
copayment for the retroperitoneal ultrasound provided on May 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-rays received at an in-network outpatient 
hospital setting provided on June 21, 2022. 
 
You asked the Plan to waive the copayment for x-rays received at an in-network outpatient hospital setting. 
You say that you should not be responsible to pay this. 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 $50 
copayment for Outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $50 copayment for x-rays received at an in-network outpatient hospital setting. 
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 received at an in-network outpatient 
hospital setting provided on June 21, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services requested are medically necessary. The 
Plan denied your request. The Plan says the enrollee doesn't meet the criteria for SNF admission. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are no identifiable skilled nursing service needs or skilled therapy service 
needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the member is 
receiving appropriate in-patient acute care and does not require transfer to a Long-Term Acute Care Hospital 
(LTACH). 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical record does not indicate that the enrollee requires services that she is not 
currently receiving. The enrollee still requires acute care services before transitioning to a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on March 15, 
2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you would like the 
ambulance services to be processed as in-network, due to there only being one ambulance in the area. 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 $290 
copayment for ambulance services. 
 
You have been asked to pay a $290 copayment for ambulance services. 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 ambulance services 
provided on March 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for electrocardiogram (EKG) on May 11, 
2022. 
 
You asked the Plan to waive the copayment for EKG. 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 a $5 
copayment for diagnostic lab services and diagnostic procedures and tests (per day, per facility). Covered 
services include, but are not limited to other outpatient diagnostic tests. 
 
You have been asked to pay a $5 copayment for EKG. 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 electrocardiogram (EKG) on May 11, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on 
June 03, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that there was nothing 
unusual during the procedure and should be billed as a regular colonoscopy. 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 $325 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $325 copayment for the diagnostic 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. 
The records show that the colonoscopy was ordered due to a specific condition of chronic diarrhea. For this reason, the procedure is considered diagnostic. Therefore, we decided that the Plan does not have to waive the 
copayment for the diagnostic colonoscopy provided on June 03, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
December 17, 2019. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you were told the claim 
was denied due to not being enrolled in Plan at time of date of service. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for an emergency room visit. This item/service 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 an emergency room visit 
provided on December 17, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a tendon sheath injection provided on  
May 18, 2022. 
 
You asked the Plan to waive the copayment for a tendon sheath injection. You say that you should not be 
responsible to pay this. 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 $350 
copayment for each Medicare-covered outpatient hospital facility visit.  
 
You have been asked to pay $193.18, which is less than the standard $350 copayment for a tendon sheath 
injection. 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 tendon sheath injection provided on May 18, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay from January 1, 2022, to 
January 24, 2022. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you are trying to manage on a 
monthly income and are worried about how to deal with this extra expense. 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 $0 
copayment each day for Medicare-covered days 1 to 20, a $150 copayment each day for Medicare-covered 
days 21 to 40 and a $0 copayment for additional Medicare-covered days, up to 100 days.  
 
You have been asked to pay a total of $1,800 for the SNF stay. This item/service falls within the Skilled 
Nursing Facility (SNF) Care benefit category. Prior to January 1, 2022, you had received 9 days of SNF care in 
the benefit period and this SNF stay applied days 10 through 32. The last 12 days of this SNF stay applied a 
$150 copayment each day, which totals $1,800. 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 SNF stay 
from January 1, 2022, to January 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laparoscopy provided on March 24, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laparoscopy. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says services were rendered by a provider who is credentialed as a Registered 
Nurse Registered Nurse First Assistant and is out-of-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 laparoscopy provided on March 24, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 9, 2022, by an OON 
provider. 
 
You asked the Plan to pay for an office visit. The Plan denied your request. The Plan says the out-of-network 
services were not authorized. 
 
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 an office visit provided on June 9, 2022, by an 
OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for ambulance on May 14, 2022, to June 20, 
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 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $100 copayment for each one-day 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 service. 
$100 x 2 = $200. Therefore, results in the total cost sharing amount of $200. 
 
 
 The enrollee has been asked to pay a $100 copayment for each ambulance. This item/service 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 copayments for 
ambulance on May 14, 2022, to June 20, 2022.