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

 
We decided that the Plan does not have to waive the copayment for the electrocardiogram (93000) provided on 
December 20, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service 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 $20 
copayment per visit for laboratory tests, non-radiological diagnostic tests, flat film x-rays, and ultrasounds.   
 
 You have been asked to pay $15.56 for the non-radiological diagnostic test provided. This is the Plans allowed 
amount for this service, which is less than the applicable copayment. 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 electrocardiogram (93000) provided on December 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth facility fee provided on February 2, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a telehealth facility fee. You say that you are appealing with supporting records. 
 The Plan denied your request. The Plan says the services were billed by and rendered by non-participating 
providers. 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 telehealth facility fee provided on February 2, 
2022, 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 a dermatology specialist office visit 
provided on January 18, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you were advised when 
you signed up for the Plan there were no copayments for specialist visits. 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 a specialist office visit.  
 
You have been asked to pay a $50 copayment for a specialist office visit. A specialist office visit falls within 
the Physician/Practitioner Services, Including Doctors Office Visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a dermatology specialist office visit provided on January 18, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Emergency department visit on January 30, 
2022 to January 31, 2022. 
 
You asked the Plan to waive the copayment for Emergency department visit. You say that you would like to 
appeal the cost share and you don't believe there should be a member responsibility for the services. 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 a $120 
copayment for Emergency department visit.  
 
You have been asked to pay a $120 copayment for Emergency department visit. Emergency department 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 department visit on January 30, 2022 to January 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services received from January 20, 2021, to October 
19, 2021. 
 
You asked the Plan to pay for the services. You say that you would like these medical and dental bills 
reimbursed through the Wellness Wallet. The Plan denied your request. The Plan says these services are not 
reimbursable with the Wellness Wallet. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The Wellness Wallet for your plan is not intended to be used for dental services. Based on this information, we 
decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for dental services received from January 20, 2021, to October 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (ECG) provided on 
December 1, 2021. 
 
You asked the Plan to waive the copayment for the ECG. You say that the visit was for a wellness check, and 
you were never told there would be an extra charge. The Plan denied your request. The Plan says the annual 
physical that took place does not include lab test, radiological diagnostic test or non-radiological diagnostic 
test. Therefore, the proper copayment 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 $30 
copayment for Medicare-covered non-radiological diagnostic services. The total amount allowed for the ECG 
was $13.70 which is less than the copayment amount of $30. Therefore, only $13.70 was charged as the 
copayment. 
 
You have been asked to pay a $13.70 copayment for the ECG. The ECG falls within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for an electrocardiogram (ECG) provided on December 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Genetic Testing provided on January 11, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Genetic Testing. 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 Genetic Testing provided on January 11, 2022 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 January 17, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you were told this provide is in-network and you 
would like to appeal the denied claim. The Plan denied your request. The Plan says the rendering provider is an 
OON provider, 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 an office visit provided on January 17, 2022, by an 
out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the infusion treatment provided on 
January 26, 2022. 
 
You asked the Plan to waive the coinsurance for the infusion treatment. You say that you have never paid for 
the infusions, and you would like the Plan to reimburse you. The Plan denied your request. The Plan says The 
proper coinsurance was applied for the service rendered and that they removed the copayment for the 
administration of the infusion. 
 
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 each Medicare-covered durable medical equipment item. The total amount allowed for the 
infusion was $1,785.08 with a coinsurance amount of $357.02 ($1,785.08 total amount x 20% coinsurance). 
 
  You have been asked to pay a $357.02 coinsurance for the infusion treatment. The infusion treatment falls 
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 the infusion treatment provided on January 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extracapsular cataract removal with insertion of intraocular 
lens prosthesis provided on January 10, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for extracapsular cataract removal with insertion of intraocular lens prosthesis. You 
say that you want the claim reconsidered for payment due to medical necessity. The Plan denied your request. 
The Plan says the service was determined to be an elective surgery (non-urgent/emergent), performed by an 
out-of-network provider without obtaining prior authorization from the health plan. The Plan also says that they 
have in-network ophthalmologists who could perform this 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 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 extracapsular cataract removal with insertion of 
intraocular lens prosthesis provided on January 10, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing services provided on August 31, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory testing services. You say that the referring provider is a contracted 
provider and has received reimbursement for his/her services. The Plan denied your request. The Plan says the 
referring provider is non-participating with the member's plan and no claim(s) have been paid. The Plan also 
says that there is no evidence that services rendered were 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 laboratory testing services provided on August 31, 
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 the outpatient clinic visit provided on September 13, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient clinic visit. You say that the enrollee did not enroll into the Plan, 
and they thought they were covered under Medicare. 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 outpatient clinic visit provided on September 
13, 2021, by an out-of-network (OON) provider.  
 
Your complaint about the enrollee never enrolling into the Plan is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Emergency Room Services on December 
29, 2021. 
 
You asked the Plan to waive the copayment for Emergency Room Services. You say that you feel the services 
should be covered because you were sent for an ultrasound but didn't receive one or have any service received. 
The Plan denied your request. The Plan says based on a review of the information received, it was determined 
that you had received emergency department services on December 29, 2021. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110 
copayment for Emergency Room Services.  
 
 You have been asked to pay a $110 copayment for Emergency Room Services. Emergency Room Services 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 Services on December 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
September 17, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you should not be 
charged due to your COVID -19 diagnosis. 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 each separate ambulance service.  
 
You have been asked to pay a $200 copayment for the ambulance transportation. Please note that there is no 
evidence of cost share waivers for COVID-19 in effect during the time of service. 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 September 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and 
management of an established patient (99335) rendered by the out-of-network (OON) provider on February 2, 
2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established 
patient (99335) rendered by the out-of-network (OON) provider on February 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom orthosis (L2755, L2350, 230107, L1960) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the custom orthosis. You say that the requested custom orthosis is medically 
necessary. The Plan denied your request. The Plan says there are contracted providers that can supply a custom 
orthosis. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a custom 
orthosis (L2755, L2350, 230107, L1960) 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 waive the copayment for cruise ship medical services on December 
3, 2021 to December 4, 2021. 
 
You asked the Plan to waive the copayment for cruise ship medical services. You say that you would like to 
appeal the cost share. The Plan denied your request. The Plan says the copayment of $65 is 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 $65 
copayment for cruise ship medical services.  
 
You have been asked to pay a $65 copayment for cruise ship medical services. 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 cruise ship medical services on December 3, 2021 to December 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery services provided on 
October 1, 2021. 
 
You asked the Plan to waive the copayment for the outpatient surgery services. You say that you were told that 
you would be considered inpatient, not outpatient. 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 outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital 
facility.  
 
 
  You have been asked to pay $325 for the outpatient surgery services. The outpatient surgery services 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 outpatient surgery services provided on October 1, 2021.