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

 
We decided that the Plan does not have to waive the cost-sharing for the follow-up office visit provided on 
September 15, 2022. 
 
You asked the Plan to waive the cost-sharing for the follow-up visit. You say that this was an annual physical 
and the visit should be covered in full. The Plan denied your request. The Plan says this cost sharing was 
charged 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 10% 
coinsurance of the approved amount with the annual deductible of $800 applied for doctor and other health care 
provider services. 
 
 
 You have been asked to pay a cost-share of $124.42 for the follow-up visit because prior to this service your 
annual deductible was not met ($124.42 allowed amount x .10 = $12.44 coinsurance) ($12.44 coinsurance + 
$111.98 deductible = $124.42). This item or service you asked the Plan to waive the cost-sharing for falls 
within the doctor and other health care provider services benefit category. The Plan has followed Medicare 
rules by clearly disclosing in the contract that there is a 10% coinsurance with the annual deductible applied, 
which applies to the doctor and other health care provider services. This cost sharing is a contractual obligation 
that had not been met at the time the follow-up visit was received on September 15, 2022. Therefore, we 
decided that the Plan does not have to waive the cost-sharing for the follow-up office visit provided on 
September 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport 
and ground mileage provided on January 26, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, emergency transport and ground 
mileage. You say that the medical records provided support the need for the ambulance transport. The Plan 
denied your request. The Plan says the ambulance transport was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 pay for the ambulance service, basic life support, 
emergency transport and ground mileage. Our reviewer says that the ambulance transport not medically 
necessary.  Our physician reviewer found the transportation via ambulance to and/or from the enrollee's doctor 
appointment was not  medically necessary. The enrollee did not require the expertise of trained personnel or the 
equipment available only on an ambulance in order to effectuate a safe transport. Transportation could have 
been provided by other means (stretcher van, wheelchair van) without endangering the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ambulance service, basic life support, emergency transport and ground 
mileage have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, 
basic life support, emergency transport and ground mileage provided on January 26, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an in-network breast ultrasound provided 
on June 22, 2022, and an in-network breast biopsy provided on July 7, 2022. 
 
You asked the Plan to waive the copayments for an in-network breast ultrasound and an in-network breast 
biopsy. You say that you were told by the staff at the facility that you would not have a copayment for these 
services and that they were covered. The Plan denied your request. The Plan says this cost sharing was charged 
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 $100 
copayment for outpatient diagnostic tests and therapeutic services and supplies, and a $350 copayment for 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. 
You have been asked to pay the allowed amount of $98.58 which is less than the $100 copayment for an 
ultrasound.  
 
You have been asked to pay a $95.58 copayment for outpatient diagnostic tests and therapeutic services and 
supplies, and a $350 copayment for an in-network breast ultrasound and an in-network breast biopsy ($98.58 + 
$350 = $448.58).  
 
This item/service falls within the outpatient diagnostic tests and therapeutic services and supplies, and 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical center 
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 an in-network breast ultrasound 
provided on June 22, 2022, and an in-network breast biopsy provided on July 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for specialist office visit provided on August 
10, 2022. 
 
You asked the Plan to reduce the copayment for specialist office visit. You say that you were told the provider 
was in-network with a copayment of $30. You now are being billed $60 and do not understand why. The Plan 
denied your request. The Plan says this cost sharing was charged 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 $60 
copayment for Physician/Practitioner services, including doctors office visits. 
 
You have been asked to pay a $60 copayment for specialist office visit. This item/service 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 reduce the copayment for specialist office visit provided on August 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH admission is 
medically necessary. The Plan denied your request. The Plan says the requested LTACH admission is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 the LTACH services. Our reviewer says 
that the requested LTACH admission is not medically necessary. Our physician reviewer found there is no 
documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving 
appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are 
not available at the acute care hospital where he is currently receiving care. There are no services available at 
the LTACH that the enrollee requires that are not available at the health care setting being offered by the health 
plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis 
and condition of the enrollee.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on July 07, 2022. 
 
You asked the Plan to pay for a nursing facility visit. You say that we depend on the facility staff to verify 
eligibility and to obtain authorization. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a nursing facility visit 
provided on July 07, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiography (93306) with 
myocardial strain imaging (speckle imaging) (93356). 
 
You asked the Plan to pre-approve a transthoracic echocardiography (93306) with myocardial strain imaging 
(speckle imaging) (93356). You say that the requested transthoracic echocardiography (93306) with myocardial 
strain imaging (speckle imaging) (93356) is medically necessary. The Plan denied your request. The Plan says 
the requested transthoracic echocardiography (93306) with myocardial strain imaging (speckle imaging) 
(93356) is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 a transthoracic echocardiography 
(93306) with myocardial strain imaging (speckle imaging) (93356). Our reviewer says that the requested 
transthoracic echocardiography (93306) with myocardial strain imaging (speckle imaging) (93356) is not 
medically necessary. Our physician reviewer found documentation is absent for planned treatment that could 
result in cardiotoxicity. Clinical guidelines do not support carrying out a TEE in this setting. In summary, there is no supportive evidence for the medical necessity of a TEE with speckle imaging in this enrollee's clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a transthoracic echocardiography (93306) with myocardial strain imaging 
(speckle imaging) (93356) have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a transthoracic echocardiography (93306) with myocardial strain imaging (speckle imaging) (93356).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Medicare Part B prescription drugs, an 
outpatient diagnostic test and medical supplies provided on July 15, 2022. 
 
You asked the Plan to waive the cost share for Medicare Part B prescription drugs, an outpatient diagnostic test 
and medical supplies. You say that you disagree with the cost share. The Plan denied your request. The Plan 
says this cost sharing was charged 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 20% coinsurance for Medicare Part B prescription drugs a 20% coinsurance for outpatient diagnostic tests/medical 
supplies and a $80 copayment for outpatient diagnostic tests/Medicare -covered radiological diagnostic 
services.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs a 20% coinsurance for 
medical supplies and a $80 copayment for an outpatient diagnostic test. The total allowed amount for the 
prescription drugs is $257.63. You are being asked to pay $51.52 ($257.63 x 20% = $51.52). The total allowed 
amount for the medical supplies is $223.70. The amount you are being asked to pay is $44.74 ($223.70 x 20% 
= $44.74). The total amount for all services is $176.26 ($80 + 51.52 + $44.74 =$176.26). 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 cost share for Medicare Part B prescription drugs, an outpatient diagnostic test and 
medical supplies provided on July 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an in-network computed tomography (CT) 
scan of the abdomen and a speech language pathology appointment on May 20, 2022, and May 27, 2022. 
 
You asked the Plan to waive the copayments for a CT scan and a speech therapy visit. You say that you were 
unclear of the copayment applied to these visits. The Plan denied your request. The Plan says this cost sharing 
was charged 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 $275 
copayment for in-network CT scans, and a $40 copayment for outpatient rehabilitation services.  
 
You have been asked to pay a $275 copayment for an in-network CT scan, and a $40 copayment for outpatient 
rehabilitation services for a CT scan and a speech therapy visit ($275 + $40 = $315 total). This item/service 
falls within the outpatient diagnostic tests and therapeutic services and supplies, and 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 copayments for an in-network computed tomography (CT) 
scan of the abdomen and a speech language pathology appointment on May 20, 2022, and May 27, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on September 02, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
September 02, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on May 18, 
2022, to June 2, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that      The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $295 copayment per day for days 1-6 for inpatient hospital care.  
 
The enrollee has been asked to pay a $295 copayment per day for days 1-6 for inpatient hospital care. You have 
been asked to pay a $295 copayment per day for days 1-6 for inpatient hospital care. The total amount for the 
inpatient care is $1,770 ($295 x 6 days = $1,770). 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 care provided on May 18, 2022, to June 2, 2022.This item/service falls within the inpatient hospital care benefit category. This means that the enrollee has been asked to pay the correct amount based on 
the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon 
enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient 
hospital care provided on May 18, 2022, to June 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for biopsy provided on September 20, 2022. 
 
You asked the Plan to pay for biopsy. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for biopsy provided on 
September 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for in-network lab services provided on 
October 26, 2022. 
 
You asked the Plan to waive the deductible for in-network lab services. You say that you should be paid the 
difference for these labs. The Plan denied your request. The Plan says this cost sharing was charged 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 $450 
deductible for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $450 deductible for in-network lab services. This item/service 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. $46.90 was applied towards your in-network 
deductible. Therefore, we decided that the Plan does not have to waive the deductible for in-network lab 
services provided on October 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on August 24, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
August 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on October 06, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says this cost sharing was charged 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 $290 
copayment for outpatient hospital services. 
 
You have been asked to pay a $290 copayment for outpatient surgery. This item/service 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 provided on October 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on October 24, 
2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that you waited an extra two hours and 
the appointment went nowhere. The Plan denied your request. The Plan says this cost sharing was charged 
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 $50 
copayment for physician/practitioner services, including doctors office visits (specialist). 
 
You have been asked to pay a $50 copayment for the office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits (specialist) 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 office visit provided on October 24, 2022.