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

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on May 
11, 2022. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that you were informed there was 
no copayment since this was a hospital discharge follow-up. 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 medical care or surgical services in a specialty physician's office.  
 
You have been asked to pay a $35 copayment for the specialist visit. The specialist visit falls within the 
Physician/Practitioner Services, Including Doctor's 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 office visit provided on May 11, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services on May 01, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you were triaged and 
placed in a room but never saw a nurse nor a physician. 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 $90 
copayment per visit for Medicare-covered emergency room visits. Emergency care refers to services that are 
furnished by a provider qualified to furnish emergency services and needed to evaluate or stabilize an 
emergency medical condition. A medical emergency is when you, or any other prudent layperson with an 
average knowledge of health and medicine, believe that you have medical symptoms that require immediate 
medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms 
may be an illness, injury, severe pain, or a medical condition that is quickly getting worse. 
 
 
 You have been asked to pay a $90 copayment for emergency room services. Emergency room services fall 
within the Emergency care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency 
room services on May 01, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a sigmoidoscopy performed on March 14, 
2022. 
 
You asked the Plan to waive the copayment for the sigmoidoscopy. You say that the test is a necessary follow-
up after surgery. 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 $250 
copayment per day for outpatient procedures and services other than colonoscopies.  
 
You have been asked to pay a $250 copayment for the sigmoidoscopy. The sigmoidoscopy 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 sigmoidoscopy 
performed on March 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on October 27, 
2021. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that the copayment should not be so 
high. 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 $55 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay a $55 copayment for an ultrasound. 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 provided on October 27, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance on April 09, 2022. 
 
You asked the Plan to waive the copayment 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 $350 
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. 
 
 
 
 You have been asked to pay a $350 copayment for 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 copayment for ambulance on April 09, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
March 8, 2021. 
 
You asked the Plan to waive the copayment for the PT services. You say that you were informed there would 
be no charge for the services. 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 $20 
copayment for physical therapy visits.  
 You have been asked to pay a $20 copayment for the PT services. The PT services fall within the Outpatient 
Rehabilitation 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 physical 
therapy (PT) services provided on March 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional two-view chest x-ray (procedure code 71046) 
provided to the enrollee on June 10, 2021. 
 
You asked the Plan to pay for the x-ray. You say that this should be paid for. The Plan denied your request. The 
Plan says the claim was already processed. 
 
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, the CPT Code Manual definition of code 71046 is [*****enter CPT Codebook definition*****]. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the x-ray. Our reviewer says that the services at issue in this 
case were not supported by the medical records. Our reviewer found that there is only evidence of a single two 
view chest x-ray done on the denied date service. The report of this x-ray appears twice in the records. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have 
to pay for an additional two-view chest x-ray (procedure code 71046) provided to the enrollee on June 10, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a full body scan provided on February 18, 
2022. 
 
You asked the Plan to waive the copayment for a full body scan. You say that you would like this copayment 
waived. 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 $195 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay a $195 copayment for a full body scan. A full body scan 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 a full body scan provided on February 18, 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 May 18, 2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you would like your copayment 
refunded as you were unsatisfied with the provider. 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 $45 
copayment for in-network physician/practitioner services, including doctor's office visits.  
 
You have been asked to pay a $45 copayment for a specialist visit. A specialist visit falls within the In-Network 
Physician/Practitioner Services, Including Doctor's 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 May 18, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care on 
October 24, 2021, to December 06, 2021. 
 
You asked the Plan to waive the copayment for skilled nursing facility (SNF) care. You say that the enrollee 
got Covid in the facility and you feel like she should not be responsible for the days spent there. The Plan 
denied your request. The Plan says the cost sharing the enrollee is 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $100 copayment per day, per admission for days 21-100 for skilled nursing facility (SNF) care. No 
prior inpatient hospital stay is required before you can be admitted to a skilled nursing facility. Our plan has a 
limit of 100 days per benefit period for Medicare-covered skilled nursing stays. There were 43 days in total. 
For days 21-43, a $100 copayment per day. 23 x $100 = $2,300. Therefore, results in the total cost sharing 
amount of $2,300.   
 
 The enrollee has been asked to pay a $100 copayment per day for skilled nursing facility (SNF) care. Skilled 
nursing facility (SNF) care falls within the skilled nursing facility (SNF) care 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 skilled nursing facility (SNF) care on October 24, 2021, to December 
06, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
March 28, 2022. 
 
You asked the Plan to waive the copayment for the PT services. You say that you were not aware that you 
would owe $30 for each visit. 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 $30 
copayment for each physical therapy visit.  
 You have been asked to pay a $30 copayment for the PT services. The PT services fall within the Outpatient 
Rehabilitation 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 physical 
therapy (PT) services provided on March 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound on May 05, 2021. 
 
You asked the Plan to waive the copayment for ultrasound. You say that the services should be covered 
because due to financial hardship and being at risk for thyroid cancer and you are requesting the copay to be 
waived to $0. 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 per day for a Medicare-covered ultrasound. Covered services include, but are not limited to 
diagnostic radiology services, such as ultrasound, nuclear cardiac imaging, PET, MRI, and CT scan. 
 
You have been asked to pay a $60 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 05, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
March 4, 2021. 
 
You asked the Plan to waive the copayment for the PT services. You say that you were informed there would 
be no charge for the services. 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 $20 
copayment for physical therapy visits.  
 You have been asked to pay a $20 copayment for the PT services. The PT services fall within the Outpatient 
Rehabilitation 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 physical 
therapy (PT) services provided on March 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
February 2, 2022, to February 4, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were unaware of 
this charge at the time of admission and feel you should not be responsible. 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 $403 
copayment per day for days 1 to 5 for inpatient hospital care.  
 
You have been asked to pay a $806 copayment for an inpatient hospital stay ($403.00 per day x 2 days = $806). 
An inpatient hospital stay falls within the inpatient hospital care benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for an inpatient hospital stay provided from February 2, 2022, to February 4, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on April 
12, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you should not have to 
pay this copayment because you were told it would be less. This copayment is too high. 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 $110 
copayment for emergency care.  
 
You have been asked to pay a $110 copayment for an emergency room visit. An emergency room visit falls 
within the Emergency Care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an 
emergency room visit provided on April 12, 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 March 3, 
2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you were supposed to speak to 
the provider on the phone but were unable to. You would like the copayment waived. 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 $35 
copayment for Physician/Practitioner services, including doctor's office visits - telehealth specialist visit.  
 
You have been asked to pay a $35 copayment for a specialist visit. A specialist visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits - Telehealth Specialist 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 a specialist visit provided on March 3, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on May 
8, 2022. 
 
You asked the Plan to waive the copayment for the ambulance 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 $317 
copayment for each one-way ambulance transport.  
 
You have been asked to pay a $317 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 May 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for a primary care visit provided on March 14, 2022. 
 
You asked the Plan to waive the cost for a primary care visit. You say that you saw your primary care provider, 
not a specialist. The Plan denied your request. The Plan says the deductible and copayment 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 $10 
copayment after paying a $100 deductible for Physician/Practitioner services, including doctors office visits.  
 
You have been asked to pay a $10 copayment, and the $32.57 remainder of your deductible for a primary care 
visit ($10 + $32.57 = $42.57). a primary care visit falls within the 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 cost for a primary care visit 
provided on March 14, 2022.