Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services, outpatient 
laboratory services, an echography, pelvic-not Ob, B-scan, and x-ray examinations of the chest provided from 
September 7, 2021, to February 10, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital services, outpatient laboratory services, an 
echography, pelvic-not Ob, B-scan, and x-ray examinations of the chest. You say that you do not agree with 
having copayments and costs for blood clot related services from the Plan. The Plan denied your request. The 
Plan says you were 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 per day for days 1-6 for inpatient hospital care. Your contract with the Plan also clearly says that 
you must pay a $10 copayment per day, per provider, for Medicare-covered laboratory services. Your contract 
with the Plan also says that enrollees must pay a $35 copayment per day, per provider, for Medicare-covered x-
ray services. 
 
You have been asked to pay a $325 copayment for 2 days of inpatient hospital services, which is a total of $650 
($325 x 2 = $650). Inpatient hospital services fall within the inpatient hospital care benefit category. You have 
also been asked to pay a $10 copayment for each outpatient laboratory services, which is a total of $20 ($10 
copayment x 2 dates of service: September 13, 2021, and December 13, 2021, = $20). You have also been 
asked to pay a $35 copayment for an echography, pelvic-not Ob, B-scan. You have also been asked to pay a 
$35 copayment for each x-ray examination of the chest, which is a total of $70 ($35 copayment x 2 dates of 
services: January 21, 2022, and February 10, 2022, = $70). Outpatient laboratory services, an echography, 
pelvic-not Ob, B-scan and x-ray examinations of the chest fall within the outpatient diagnostic tests and 
therapeutic 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 inpatient hospital 
services, outpatient laboratory services, an echography, pelvic-not Ob, B-scan, and x-ray examinations of the 
chest provided from September 7, 2021, to February 10, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (00731) provided November 30, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says a corrected claim is needed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 00731 is not supported in the medical record. Specifically, the claim was not billed with 
a valid modifier. Based on this information, we decided that Medicare rules for coverage of the anesthesia 
services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services 
(00731) provided November 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Hospital discharge day management services provided on 
June 15, 2021. 
 
You asked the Plan to pay for the Hospital discharge day management services. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the enrollee 
enrolled in hospice from June 15, 2021, through July 11, 2021. The Plans says, per Medicare guidelines, the 
provider must bill Original Medicare for the services provided on June 15, 2021. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the Hospital discharge day management services provided on 
June 15, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room visit provided on 
December 6, 2021. 
 
You asked the Plan to waive the copayment for emergency room visit. You say that your PCP told you to go to 
the emergency room so you should not have a copayment. The Plan denied your request. The Plan says 
copayment 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 $120 
copayment for each Medicare-covered in-network and out-of-network emergency room visit.  
 
  You have been asked to pay $120 copayment for emergency room visit. The 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 emergency 
room visit provided on December 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for office visits provided from November 19, 
2021, to December 17, 2021. 
 
You asked the Plan to waive the copayments for the office visits. You say that you have had these services 
done in the past with no copayments. 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 $15 
copayment for each primary care provider (PCP) in-person visit.  
 
You have been asked to pay a $15 copayment for each of the three office visits, for a total of $45 ($15 
copayment x 3 visits = $45). The office visits fall 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 copayments for office visits provided 
from November 19, 2021, to December 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 1, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to appeal the denial of the 
claim. The Plan denied your request. The Plan says the services and labs were not authorized by and were not 
referred by a participating provider. The provider is out-of-network and it was determined these services were 
not urgent or emergent. 
 
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 December 1, 2021 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (00813) provided December 16, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim was not billed with a valid place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 00813 is not supported in the medical record. Specifically, the place of service listed on 
the claim was 22 (outpatient hospital), however the record shows the enrollee was an inpatient on this date of 
service. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have 
not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (00813) 
provided December 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 1, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the laboratory services. You say that the test was requested by the ordering 
physician. The Plan denied your request. The Plan says the rendering and referring providers are both OON 
providers and the service rendered was not urgent or emergent. 
  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 the laboratory services provided on December 1, 
2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient facility services provided on 
December 22, 2021. 
 
You asked the Plan to waive the copayment for outpatient facility services. You say that the service was not 
done at a hospital, it was done at an office of a pain management clinic. The Plan denied your request. The Plan 
says the copayment was applied correctly.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay, when in-network, a $350 copayment per visit. Unless the provider writes an order to admit you as an 
inpatient to the hospital, you are an outpatient and pay the cost sharing amounts for outpatient surgery. 
 
  The enrollee has been asked to pay $350 for outpatient facility services. Outpatient facility services fall within 
the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers 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 outpatient facility 
services provided on December 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Physical Therapy Evaluations provided on September 28, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Physical Therapy Evaluations. You say that the member presented the incorrect 
insurance card at the time of service. Due to the patient misleading the office of incorrect insurance, the office 
was unable to obtain authorization. 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 Physical Therapy Evaluations provided on 
September 28, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
December 2, 2021. 
 
You asked the Plan to waive the coinsurance for ambulance transportation. You say that you need a reduction 
in the copayment due to high cost. The Plan denied your request. The Plan says coinsurance 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 $325 
copayment per trip for Medicare-covered ambulance services.  
 
  You have been asked to pay $325 copayment for ambulance transportation. 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 December 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 3, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that this was an office visit, and you would like to be 
advised why an authorization is required for an office visit. You also say that you have this provider as 
credentialed and in-network. The Plan denied your request. The Plan says this provider is out-of-network with 
the Plan, and authorization was not obtained prior to the services being rendered. 
 
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 November 3, 2021, by 
an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency transportation provided on November 17, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the non-emergency transportation. You say that the service was covered before, 
and you feel it should be covered again. The Plan denied your request. The Plan says the enrollee was previous 
approved for 2 previous dates of service but there was no authorization or approval for November 17, 2021. 
Therefore, the service was not approved. 
  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 the non-emergency transportation provided on 
November 17, 2021, 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 a catheterization procedure performed on 
March 12, 2021. 
 
You asked the Plan to waive the copayment for the catheterization. You say that the surgery was unnecessary. 
You say another specialist informed you of other options. 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 per date of service for surgery and other services provided at an outpatient hospital.  
 
You have been asked to pay a $350 copayment for the catheterization. The catheterization 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 catheterization procedure 
performed on March 12, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an endoscopy provided on December 15, 
2021. 
 
You asked the Plan to reduce the copayment for the endoscopy. You say that it was not a surgical procedure. 
You say you thought it would only be a $15 copayment for a specialist 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 $50 
copayment per day for outpatient procedures and services, including endoscopies.  
 
You have been asked to pay a $50 copayment for the endoscopy. The endoscopy 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 an endoscopy provided on December 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health visit provided on December 29, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the home health visit. You say that it is the facilities responsibility to obtain the 
authorization and you would like the claim reprocessed for payment. The Plan denied your request. The Plan 
says the rendering provider is an OON provider and there was no referral from an in-network provider or an 
approved authorization. Also, the service rendered was not urgent or emergent. 
 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 the home health visit provided on December 29, 
2021, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services provided on 
November 16, 2021. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you have very low 
income and are unable to afford this cost. The Plan denied your request. The Plan says the copayment was 
applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for each in-network Medicare-covered outpatient hospital visit under the ConnectiCare Flex Plan 3. 
 
 
  You have been asked to pay the allowed amount of $143.97 instead of the standard $325 copayment, for the 
outpatient hospital services. Outpatient hospital services fall 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 copayment for outpatient hospital services provided on 
November 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical oncology second opinion to be rendered by 
the out-of-network (OON) provider. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are in-network providers available to render the 
requested service. 
 
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 service at issue in this appeal. We found no exception that would require the 
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve a surgical 
oncology second opinion to be rendered by the out-of-network (OON) provider.