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

 
We decided that the Plan does not have to waive coinsurance for the office visit on December 21, 2021. 
 
You asked the Plan to waive coinsurance for office visit. You say that the cost of this office visit should have 
been covered in full. 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 20% 
coinsurance for provider and professional services at an in-network PCPs office and specialists office.  
 
  You have been asked to pay $43.67, which is 20% of the allowed amount for the office visit. The allowed 
amount is $218.34 (20% x $218.34 = $43.67). The office visit falls within the Physician/Practitioner services, 
including doctor's office 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 coinsurance for the office visit 
on December 21, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Mental Health services provided on November 9, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Outpatient Mental Health services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network 
and 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 Outpatient Mental Health services provided on 
November 9, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and coinsurance for carpal tunnel surgery 
performed on December 7, 2021. 
 
You asked the Plan to waive the deductible and coinsurance for the carpal tunnel surgery. You say that the 
provider should be in-network. The Plan denied your request. The Plan says the correct amounts were applied 
to your deductible and coinsurance. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $500 out-of-network (OON) deductible which applies to certain items 
and services. 
 
Your contract with the Plan also clearly says that you must pay a 40% coinsurance after the deductible is met 
for surgical services.  
The item or service you asked the Plan to waive the deductible and coinsurance for falls within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $500 out-of-
network (OON) deductible which applies to certain items and services. This cost sharing is a contractual 
obligation that had not been met at the time the carpal tunnel surgery was performed on December 7, 2021.  
 
The file shows that the Plan verified the providers out-of-network status, and applied the $500 to the 
deductible. You have been asked to pay $125.08 for the remainder of the cost for tissue transfer, which is 40% 
of the allowed amount ($812.72 allowed amount - $500 deductible = $312.72 x 40% coinsurance = $125.08). 
You have also been asked to pay $150.90 for the carpal tunnel procedure, which is also 40% of the allowed 
amount ($377.26 allowed amount x 40% coinsurance = $150.90). The total for the procedure is $775.98. 
Therefore, we decided that the Plan does not have to waive the deductible and coinsurance for carpal tunnel 
surgery performed on December 7, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the cost share for a specialist office visit and a diagnostic laryngoscopy 
provided on January 20, 2022. 
 
You asked the Plan to waive the cost share for a specialist office visit and a diagnostic laryngoscopy. You say 
that you do not understand the amount covered by the Plan since you have seen this doctor before, and it was 
covered in full. The Plan denied your request. The Plan says that 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. Your 
contract with the Plan says that enrollees must pay $0 copayment for a specialist office visit and surgery 
services at a specialist office. 
 
The Plan says you have a $233 deductible and must pay 20% coinsurance for a specialist office visit and a 
diagnostic laryngoscopy. Based on the Plan contract, there is no annual deductible, and you cannot be asked to 
pay more than a $0 copayment for a specialist office visit and a diagnostic laryngoscopy.  Therefore, we 
decided that the Plan has to waive the cost share for a specialist office visit and a diagnostic laryngoscopy 
provided on January 20, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on November 18, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the service was medically 
necessary. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on November 18, 2021, 
by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for PET scan provided on August 19, 2021. 
 
You asked the Plan to waive the copayment for PET scan. You say that you paid this amount already to the 
provider. 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 $125 
copayment for Medicare-covered, radiological diagnostic services, not including x-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic).  
 
  You have been asked to pay $125 copayment for PET scan. The PET 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 PET scan provided on August 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a bevacizumab injection provided on 
September 27, 2021. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you have been getting this injection 
for years and have never had an additional charge. 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 20% 
coinsurance for Part B drugs. The contract also says that if a Part B drug is administered in the office, you are 
subject to 20% coinsurance in addition to the office member liability. 
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
$41.60, which is 20% coinsurance of the allowed amount for an injection ($208 allowed amount x 20% 
coinsurance = $41.60). An injection falls within the Medicare Part B Prescription Drugs benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for a bevacizumab injection provided on September 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit provided on December 28, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the domiciliary visit provided on December 28, 2021, by an out-
of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oxygen supplies (E1390, E0431) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the oxygen supplies. You say that the oxygen equipment is medically 
necessary. The Plan denied your request. The Plan says there are network providers available. 
 
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 
oxygen supplies (E1390, E0431) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on December 15, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the home health visit. You say that it was medically necessary to treat the 
enrollee 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 a home health visit provided on December 15, 
2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on November 24, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the rendering physician is a 
hospitalist physician with the group and depends upon the hospital staff to verify eligibility and to obtain the 
proper authorization from the patient's insurance company. The Plan denied your request. The Plan says this 
provider is not a network provider with the Plan and the services were not referred by a network provider or 
rendered in an in-network facility. The Plan also says that they have also determined that these services are not 
urgent or emergent, nor were they approved in advance. 
 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 a domiciliary or rest home visit provided on 
November 24, 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 Office Visit provided on November 19, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Office Visit. You say that you would like to appeal the denial of the claim. The 
Plan denied your request. The Plan says 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 Office Visit provided on November 19, 2021 by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a hospital bed and gel mattress provided 
on December 13, 2021. 
 
You asked the Plan to waive the coinsurance for a hospital bed and gel mattress. You are asking why your 
mothers insurance does not cover this. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay 20% coinsurance for in-network durable medical equipment.  
 
The enrollee has been asked to pay $10.75, which is 20% coinsurance of the allowed amount for a hospital bed 
($53.77 allowed amount x 20% coinsurance = $10.75). The enrollee has also been asked to pay $25.69, which is 20% coinsurance of the allowed amount for a gel mattress ($128.47 allowed amount x 20% coinsurance = 
$25.69). The enrollee has been asked to pay a total of $36.44 ($10.75 + $25.69 = $36.44). A hospital bed and 
gel mattress fall within the Durable Medical Equipment (DME) and Related Supplies benefit category. This 
means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost 
sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided 
that the Plan does not have to waive the coinsurance for a hospital bed and gel mattress provided on December 
13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for post-cataract laser surgery provided on 
January 24, 2022. 
 
You asked the Plan to waive the copayment for post-cataract laser surgery. You say that you had to go back for 
laser surgery on your left eye and the procedure was done in 5 minutes or less. You say that you consider laser 
if necessary be part of the original surgery. The Plan denied your request. The Plan says you have been charged 
the correct copayment 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 outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital 
facility.  
 
 
 You have been asked to pay a $200 copayment for post cataract laser surgery. Surgery falls within the 
Outpatient hospital services benefit category.  This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
post-cataract laser surgery provided on January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy on October 4, 2021. 
 
You asked the Plan to waive the copayment for physical therapy visit. You say that you have no liability for 
this visit, but you are still being billed $24.51. 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 $35 
copayment for each Medicare-covered therapy visit.  
 
You have been asked to pay $24.51, which is less than the standard $35 copayment for the physical therapy 
visit. Physical therapy visits 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 on October 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit on December 11, 2021. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you went to urgent care and 
after waiting a significant amount of time you were told that no antibiotic would be prescribed. The Plan denied 
your request. The Plan says you have been charged the correct copayment 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 urgently needed services at a preferred urgent care center.  
 
 
  
You have been asked to pay a $30 copayment for an urgent care visit. An urgent care visit falls within 
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 on December 11, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for physical therapy provided from January 21, 
2022 to January 27, 2022. 
 
You asked the Plan to waive the deductible for physical therapy. You say that you don't understand all the fine 
points, but understood that you had permission for four times for a no charge. The Plan denied your request. 
The Plan says the deductible applied correctly 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible which applies to outpatient rehabilitation services.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
rehabilitation services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is 
a $750 deductible which applies to outpatient rehabilitation services. This cost sharing is a contractual 
obligation that had not been met at the time physical therapy was received on January 21, 2022 to January 27, 
2022. Therefore, we decided that the Plan does not have to waive the deductible for physical therapy provided 
from January 21, 2022 to January 27, 2022.