Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF care. You say that you need the physical therapy help with your 
Parkinsons and to get your strength back. The Plan denied your request. The Plan says you do not require the 
daily skilled therapy or nursing services required to qualify for a skilled nursing facility stay.  
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 SNF 
care is not medically necessary. Our physician reviewer found that you do not have daily skilled nursing needs 
that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have 
daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled 
nursing facility (SNF) setting. 
 
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 a skilled nursing facility (SNF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy (PT) services and X-rays 
of the neck provided on January 14, 2022, and February 2, 2022. 
 
You asked the Plan to waive the copayments for the PT services and X-rays. You say that the post-op care 
should be covered. 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 each therapy visit. 
 
Your contract with the Plan also clearly says that you must pay a $20 copayment for X-rays and ultrasounds. 
 You have been asked to pay a $20 copayment for the PT services. The PT services fall within the Outpatient 
Rehabilitation Services benefit category. You have also been asked to pay a $20 copayment for the X-rays. The 
X-rays fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The 
total for all services is $40. 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 physical therapy (PT) 
services and X-rays of the neck provided on January 14, 2022, and February 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for nuclear medicine services provided on 
December 15, 2021. 
 
You asked the Plan to waive the copayment for nuclear medicine services. You say that that this charge should 
be covered. The Plan denied your request. The Plan says the copayment applied 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 $360 
copayment for nuclear medicine services provided at an outpatient hospital. 
 
You have been asked to pay $331.16 which is less than the standard $360 copayment for nuclear medicine 
services. Nuclear medicine services fall within the Outpatient diagnostic tests and therapeutic services and 
supplies benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for nuclear medicine services 
provided on December 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injection provided on January 3, 2022. 
 
You asked the Plan to waive the coinsurance for injection. You say that you were not told about the 
coinsurance so it should be covered. The Plan denied your request. The Plan says the coinsurance applied 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 chemotherapy drugs, infusion drugs, and all other drugs. 
 
You have been asked to pay $262.97 which is 20% of the allowed amount for the injection. The allowed 
amount is $1,314.83(20% x $1,314.83= $262.97).  Injection fall 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 injection provided on January 3, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on December 29, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a home health visit. You say that an authorization should be on file, 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 29, 
2021, by an out-of-network (OON) provider.
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 December 
2, 2021. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you thought COVID-19 tests 
were free and you are being charged for an office visit that didn't occur. The Plan denied your request. The Plan 
says the copayment applied 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 $45 
copayment for each covered office visit to other providers for urgently needed services. 
 
 
 
 You have been asked to pay $45 copayment for an urgent care visit. Urgent care visit falls within the Urgently 
needed services benefit category. The records show the visit was provided at an urgent care facility. 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 December 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on January 27, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that it is the facilities responsibility to obtain prior 
authorization and the services were rendered in good faith. 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 January 27, 2022, 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital rehabilitation provided 
from December 13, 2021, to December 20, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital rehab. You say that this was an inpatient 
rehab stay and not a hospital stay so it should be covered. The Plan denied your request. The Plan says the 
copayment applied 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 day for days 1 through 6 for each Medicare-covered hospital admission/stay. $0 for additional 
hospital days.  
 
 You have been asked to pay a total of $1,950 copayment ($325 x 6 = $1,950). Inpatient hospital rehab 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 
inpatient hospital rehabilitation provided from December 13, 2021, to December 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a knee orthosis (brace) provided on March 
4, 2020. 
 
You asked the Plan to waive the coinsurance for the knee brace. You say that you should not have to pay for a 
piece of equipment that did not work for you. The Plan denied your request. The Plan says the correct 
coinsurance was applied. 
 
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% 
coinsurance for prosthetic devices and related supplies, including braces.  
 
The file shows that you were supplied with the knee brace on March 4, 2020. Therefore, you have been asked 
to pay a total of $179.78, which is 20% of the allowed amount for the knee brace ($898.90 allowed amount x 
20% coinsurance = $179.78). The knee brace falls within the Prosthetic Devices and Related Supplies benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a knee orthosis (brace) provided on March 4, 
2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for ambulance transportation provided on 
February 3, 2022. 
 
You asked the Plan to waive the coinsurance for the ambulance transportation. You say that the cost should be 
covered due to your COVID-19 diagnosis. The Plan denied your request. The Plan says the correct coinsurance 
was applied. 
 
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 an 18% 
coinsurance for ambulance trips. 
 
Service Allowed Amount 18% Coinsurance 
Ambulance Service $224.41 $40.39 
Ambulance Mileage $211.73 $38.11 
Total:  $78.50  
The file shows that your diagnosis for the service was not related to COVID-19. Therefore, you have been 
asked to pay $78.50, which is 18% of the allowed amount 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 
coinsurance for ambulance transportation provided on February 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic mammogram provided on 
March 28, 2022. 
 
You asked the Plan to waive the copayment for diagnostic mammogram. You say that this was a routine 
mammogram and should be covered. The Plan denied your request. The Plan says the copayment applied 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 $50 
copayment for diagnostic procedures and tests taken at any other location besides a physicians office.  
 
You have been asked to pay $50 copayment for the diagnostic mammogram. Mammograms fall within the 
Outpatient diagnostic tests and therapeutic serviced 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 diagnostic mammogram provided on March 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ECG provided on January 28, 2022. 
 
You asked the Plan to waive the copayment for ECG. You say that this charge should be covered. The Plan 
denied your request. The Plan says the copayment applied 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 
copayment for Medicare-covered non-radiological diagnostic services. 
 
You have been asked to pay $14.96 which is less than the standard $20 copayment for ECG. ECGs 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 the ECG provided on January 28, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
February 13, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you stayed 
overnight in the emergency room so the copayment should be waived. 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 for ground ambulance services. The copayment is waived if admitted to the hospital as an inpatient.  
 
The record shows that you were kept overnight in the emergency room under observation status. The record 
does not show a written order from the doctor to admit you as an inpatient. Therefore, you have been asked to 
pay a $250 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 February 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the annual wellness visit provided on 
December 30, 2021. 
 
You asked the Plan to waive the deductible for an annual wellness visit. You say that you did not know the 
provider was out of network so you should not be charged. The Plan denied your request. The Plan says the 
deductible applied is correct. 
 
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 preventive services from an out-of-
network provider. After the deductible has been meet there is a 40% coinsurance for out of network annual 
wellness visits. 
 
The item or service you asked the Plan to waive the deductible for falls within the Annual wellness visit benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible which applies to preventive services from an out-of-network provider. This cost sharing is a 
contractual obligation that had not been met at the time the annual wellness visit was received on December 30, 
2021. Therefore, we decided that the Plan does not have to waive the deductible for the annual wellness visit 
provided on December 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for ambulance transportation provided on 
January 12, 2022, and January 13, 2022. 
 
You asked the Plan to waive the copayments 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 $250 
copayment for each one-way ambulance trip. 
 
You have been asked to pay a $250 copayment for the ambulance transportation provided on January 12, 2022. 
You have also been asked to pay $238.54, which is less than the $250 copayment for the ambulance 
transportation provided on January 13, 2022. The total for both trips is $488.54. 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 copayments for 
ambulance transportation provided on January 12, 2022, and January 13, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a nasal endoscopy performed on November 
19, 2021. 
 
You asked the Plan to waive the copayment for the nasal endoscopy. You say that you were not aware of any 
copayment at the time of service. 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 $100 
copayment for surgery or other services provided at an outpatient hospital or ambulatory surgical center.  
 
You have been asked to pay a $100 copayment for the nasal endoscopy. The nasal endoscopy falls within the 
Outpatient Surgery and Other Medical 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 nasal endoscopy 
performed on November 19, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ER visit provided on November 19, 
2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that this should be covered because this is 
where the hospital sent you. The Plan denied your request. The Plan says the copayment applied 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 $90 
copayment for emergency care.  
 
You have been asked to pay $90 copayment for the ER visit. ER visits falls within the Emergency care benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the ER visit provided on November 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for full body jacket back brace provided on 
December 28, 2021. 
 
You asked the Plan to waive the coinsurance for full body jacket back brace. You say that this should be 
covered since it was the wrong size originally. The Plan denied your request. The Plan says the coinsurance 
applied 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 Medicare covered items.  
 
You have been asked to pay $267.86 which is 20% of the allowed amount for the full body jacket back brace. 
The allowed amount is $1,339.30 (20% x $1,339.30=$267.86). Full body jacket back braces fall within the 
Durable medical equipment (DME) and related supplies benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the coinsurance for full body jacket back brace provided on December 28, 2021.