Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a comprehensive eye exam provided on 
February 11, 2022. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you thought this was a routine 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 for services to diagnose and treat a disease or condition of the eye.  
 
The record shows that you were seen for cataracts, which makes the exam diagnostic instead of routine. 
Therefore, you have been asked to pay $40, which is less than the $50 copayment for the eye exam. The eye 
exam falls within the Vision 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 a 
comprehensive eye exam provided on February 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
abdomen and pelvis provided on December 6, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that this was a routine urology visit and 
the services 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 $200 
copayment for diagnostic radiology services, such as CT scans.  
 
You have been asked to pay a $200 copayment for the CT scan. The CT 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 computed tomography (CT) scan of the abdomen and pelvis provided on December 6, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on February 9, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that you were not aware of the requirement of obtaining a 
prior authorization, specifically for this member's plan type at the time of rendering services. The Plan denied 
your request. The Plan says the rendering provider is a non-participating provider and there is no referring 
provider involved in these services. The Plan also says that they did not authorize any services for this provider 
nor for the facility. 
 
 
 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 drug testing provided on February 9, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a comprehensive eye exam provided on 
March 2, 2022. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you thought this was a routine 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 $45 
copayment for each eye exam to diagnose and treat diseases and conditions of the eye.  
 
The record shows that you were seen for a cataract evaluation. For this reason, the exam is considered 
diagnostic instead of routine. Therefore, you have been asked to pay a $45 copayment for the eye exam. The 
eye exam falls within the Vision 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 a 
comprehensive eye exam provided on March 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the outpatient surgery provided on 
October 1, 2021. 
 
You asked the Plan to waive the coinsurance for the outpatient surgery. You say that at the time of your 
enrollment, 30% was not part of the package and you were never notified of a change in your plan. The Plan 
denied your request. The Plan says the coinsurance 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 30% 
coinsurance for each in-network surgical or observation room service you get at an outpatient hospital.  
 
You have been asked to pay $6,934.66 for the outpatient surgery. The outpatient 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 coinsurance for 
the outpatient surgery provided on October 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
January 7, 2022, to January 14, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that the stay was medically 
necessary. The Plan denied your request. The Plan says the enrollee was 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 $25 per day for days 1-5 and $0 per day for days 6-90 for each inpatient admission.  
 
The file shows that the enrollee was in the hospital from January 7, 2022, to January 14, 2022. Therefore, the 
enrollee was asked to pay $25 per day for the first 5 days of inpatient care. The total for the stay is $125 ($25 
copayment x 5 days = $125). The inpatient care falls within the Inpatient Hospital Care benefit category. This 
means that the enrollee was 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 inpatient hospital care provided from January 7, 2022, 
to January 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging, 
tomographic (SPECT) test (78452) provided on February 18, 2022. 
 
You asked the Plan to waive the copayment for the SPECT test. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $325 copayment for the SPECT test. SPECT tests 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 myocardial perfusion imaging, tomographic (SPECT) test (78452) provided on February 18, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Fulphila injection provided on January 
3, 2022. 
 
You asked the Plan to waive the coinsurance for an injection. You say that your doctor did not tell you how 
much the injection was going to cost. 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.  
 
You have been asked to pay $946.60, which is 20% coinsurance of the allowed amount for an injection 
($4,732.98 allowed amount x 20% coinsurance = $946.60). 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 Fulphila injection 
provided on January 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for cataract surgery performed on March 18, 
2022. 
 
You asked the Plan to reduce the copayment for the cataract surgery. You say that you were informed that the 
copayment would only be $45. 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 $245 
copayment for each surgery in an ambulatory surgical center.  
 
You have been asked to pay a $245 copayment for the cataract surgery. The cataract surgery 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 cataract surgery performed 
on March 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for X-rays of the chest provided on January 19, 
2022. 
 
You asked the Plan to waive the copayment for the X-rays. You say that you were not informed of any 
copayments 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 $30 
copayment for basic radiological services provided at a free-standing radiological facility.  
 
You have been asked to pay a $30 copayment for the X-rays. The X-rays 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 X-rays of the chest provided on January 19, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy services provided on 
November 24, 2021. 
 
You asked the Plan to waive the copayment for the physical therapy services. You say that the services should 
be covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing 
applied correctly based on the services provided. 
 
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 $40 
copayment for Outpatient rehabilitation services.  
 
 
  You have been asked to pay a $40 copayment for out-of-network physical therapy services. The record 
indicates that the rendering provider is out-of-network with the Plan. Physical therapy 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 services provided on November 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye exam provided on February 11, 
2022. 
 
You asked the Plan to waive the copayment for an eye exam. You say that this should be covered because your 
exam was coded for cataracts which you say is incorrect. You say that this was a routine eye exam. 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 $50 
copayment for each Medicare-covered outpatient visit for services to diagnose and/or treat a disease or 
condition of the eye.  
 You have been asked to pay $40, which is less than the standard $50 copayment for an eye exam. The eye 
exam falls within the Vision 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 eye exam provided on February 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the EKG received on February 15, 2022. 
 
You asked the Plan to waive the copayment for the EKG. You say that you are complaining about the $5 
charge because you already paid your $35 copayment. 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 $5 
copayment for diagnostic lab services and diagnostic procedures and tests (per day, per facility). 
 
You have been asked to pay $5 for the EKG. The EKG 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 
the EKG received on February 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a podiatry visit, foot X-rays, and injections 
of dexamethasone and triamcinolone provided on January 26, 2022. 
 
You asked the Plan to waive the deductible for the podiatry visit, X-rays, and injections. You say that you do 
not know why the Plan did not pay anything on this claim. The Plan denied your request. The Plan says the 
correct amount was applied to your deductible. 
 
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 deductible which applies to certain items and services.  
 
The services you asked the Plan to waive the deductible for fall within the Podiatry Services, Outpatient 
Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers, and Medicare Part B Prescription Drugs benefit categories. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is $500 deductible which applies to certain items and services. This 
cost sharing is a contractual obligation that had not been met at the time the podiatry visit, X-rays, and 
injections were received on January 26, 2022. Therefore, we decided that the Plan does not have to waive the deductible for a podiatry visit, foot X-rays, and injections of dexamethasone and triamcinolone provided on 
January 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a screening mammography bilateral and a screening digital 
mammography provided on December 16, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a screening mammography bilateral and a screening digital mammography. You 
say that you are appealing with supporting records. The Plan denied your request. The Plan says the rendering 
provider is a non-participating provider and there is no referring provider involved in these services. The Plan 
also says that they did not authorize any services for this provider or facility. 
 
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 screening mammography bilateral and a 
screening digital mammography provided on December 16, 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 an office visit provided on July 7, 2021 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. 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 an office visit provided on July 7, 2021 by an out-
of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy services provided on 
December 20, 2021. 
 
You asked the Plan to waive the copayment for the physical therapy services. You say that the services should 
be covered as you disagree with the charges and that they werent provided out-of-network. The Plan denied 
your request. The Plan says the cost-sharing applied correctly based on the services provided. 
 
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 $40 
copayment for Outpatient rehabilitation services.  
 
 
  You have been asked to pay a $40 copayment for the out-of-network physical therapy services. The record 
indicates that the rendering provider is out-of-network. Physical therapy 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 services provided on December 20, 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 7, 
2022 to January 27, 2022. 
 
You asked the Plan to waive the deductible for physical therapy. You say that you were under the impression 
that the rehabilitation would be covered because it was part of your knee replacement. The Plan denied your 
request. The Plan says 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 7, 2022 to January 27, 
2022. Therefore, we decided that the Plan does not have to waive the deductible for physical therapy provided 
from January 7, 2022 to January 27, 2022.