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

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
February 10, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you feel you should not 
be required to pay twice due to the hospital not having the oxygen needed. 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 $275 
copayment for each ambulance trip. You had one (1) ambulance trip. The Plan charged you $275 for each 
service. 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 ambulance services provided on February 
10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a physiologic study of extremity arteries 
provided on April 29, 2022. 
 
You asked the Plan to waive the copayment for the artery study. You say that the procedure was not necessary. 
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 $75 
copayment for each diagnostic procedure and test performed by a provider other than your primary care 
physician.  
 
You have been asked to pay a $75 copayment for the artery study. The artery study 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 physiologic study of extremity arteries provided on April 29, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you were not taken via 
ambulance, but a van with two staff members. The Plan denied your request. The Plan says you were charged 
this cost sharing 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 $350 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $350 for these 
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 the ambulance services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an endoscopy performed on April 15, 2022. 
 
You asked the Plan to waive the copayment for the endoscopy. You say that you were advised to submit the 
bill to insurance. 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 surgery or services provided at an ambulatory surgical center.  
 
You have been asked to pay a $250 copayment for the endoscopy. The endoscopy 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 waive the copayment for an endoscopy performed on April 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for colonoscopy on June 30, 2021. 
 
You asked the Plan to waive the copayment for colonoscopy. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says the cost sharing you are being charged 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 $250 
copayment for outpatient surgery for each Medicare-covered outpatient hospital facility visit.  If you are having 
surgery in a hospital facility, you should check with your provider about whether you will be an inpatient or 
outpatient. Unless the provider writes an order to admit you as an inpatient to the hospital, you are an outpatient 
and pay the cost-sharing amounts for outpatient surgery. Even if you stay in the hospital overnight, you might 
still be considered an outpatient. 
 
 
 
 You have been asked to pay a $250 copayment for colonoscopy. Colonoscopy 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 waive the copayment for colonoscopy on June 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on 
April 13, 2022. 
 
You asked the Plan to waive the copayment for the mammogram. You say that the service should be covered as 
a preventive 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 $75 
copayment for diagnostic procedures and tests.  
 
The records show that a screening mammogram was performed on March 9, 2022, with results showing 
asymmetry in the right breast. The diagnostic mammogram was provided for this reason. Therefore, you have 
been asked to pay a $75 copayment for the mammogram. The mammogram 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 diagnostic mammogram provided on April 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair (K0001). 
 
You asked the Plan to pre-approve the manual wheelchair. You say that the standard wheelchair is medically 
necessary for when you cannot use the power wheelchair. The Plan denied your request. The Plan says you 
already have a power wheelchair. A second wheelchair is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that is made for only one wheelchair at a time. 
Backup chairs are denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. The record shows a power wheelchair has already been provided. 
Backup chairs are non-covered. Based on this information, we decided that Medicare rules for coverage of the 
manual wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
manual wheelchair (K0001).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an abdominal ultrasound provided on April 
11, 2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you do not know why insurance 
did not pay any portion of the claim. 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 $125 
copayment for radiological diagnostic services, including ultrasounds.  
 
You have been asked to pay $92.84, which is less than the $125 copayment for the ultrasound. The ultrasound 
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 abdominal ultrasound provided on April 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for podiatry services provided from January 
12, 2022, to February 24, 2022. 
 
You asked the Plan to waive the copayments for the podiatry services. You say that you do not feel you should 
owe for these services. 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 each podiatry service.  
 You have been asked to pay a $30 copayment for each visit for the podiatry services. The total for the two 
visits is $60. The podiatry services fall within the Podiatry 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 podiatry services provided from January 12, 2022, to February 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient rehabilitation care provided from 
February 24, 2022, to March 1, 2022. 
 
You asked the Plan to waive the copayment for the inpatient rehab. You say that you feel you were charged 
twice for one stay. 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 $350 per 
day for days 1-5 and $0 per day after day 5 for each inpatient admission, including transfers to a separate 
facility type.  
 
The file shows that you were in the rehab facility from February 24, 2022, to March 1, 2022. Therefore, you 
have been asked to pay $350 per day for days 1-5 of inpatient rehab. The total for your stay is $1,750 ($350 
copayment x 5 days = $1,750). The inpatient 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 rehabilitation care provided from February 24, 
2022, to March 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral appliance (E0486). 
 
You asked the Plan to pre-approve the oral appliance. You say that this item is medically necessary. The Plan 
denied your request. The Plan says the records do not support this item. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an oral appliance (E0486). have been 
met. The records provided are from 2019 and 2020. No recent clinical records were provided. Without recent 
medical records, the service is not supported. Therefore, we decided that the Plan does not have to pre-approve 
an oral appliance (E0486).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on February 16, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you should not have a secondary 
copayment for this procedure. The Plan denied your request. The Plan says the copayment applied was 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 $135 
copayment for other outpatient diagnostic tests - radiological diagnostic services, not including x-rays.  
 
You have been asked to pay a $135 copayment for an ultrasound. An ultrasound falls within the other 
Outpatient Diagnostic Tests - Radiological Diagnostic Services, Not Including X-Rays 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 ultrasound provided on February 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5258) provided January 25, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you were misled because no one told you you 
needed to use a specific provider. The Plan denied your request. The Plan says the hearing aids are not covered 
because they were purchased OON. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans specified hearing vendor. 
 
We looked at the file and the Plan's rules. In this case the hearing aids were not purchased from the Plans 
hearing vendor. Based on this information, we decided that the Plan's rules for coverage of the hearing aids 
have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5258) 
provided January 25, 2022, by an out-of-network (OON) provider.  
 
Your complaint about potentially receiving incomplete or inaccurate information from your insurance agent 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar indirect posterior decompression and fusion 
with instrumentation and allograft at L4-L5 with Stabilink interspinous fixation device. 
 
You asked the Plan to pre-approve lumbar indirect posterior decompression and fusion with instrumentation 
and allograft at L4-L5 with Stabilink interspinous fixation device. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 lumbar indirect posterior 
decompression and fusion with instrumentation and allograft at L4-L5 with Stabilink interspinous fixation 
device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the stabilink device is experimental. More research is 
needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar indirect posterior decompression and fusion with instrumentation and allograft at L4-L5 with Stabilink interspinous fixation device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve lumbar indirect posterior decompression and fusion with instrumentation 
and allograft at L4-L5 with Stabilink interspinous fixation device.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care on 
January 27, 2022, February 24, 2022. 
 
You asked the Plan to waive the copayment for skilled nursing facility (SNF) care. You say that you were 
unaware that the service had a copayment. You are currently experiencing financial difficulties because you 
need around the clock care at home. This copayment could cause finical hardship and you are concerned with 
your financial standings if you must pay this copayment. The Plan denied your request. The Plan says the cost 
sharing you are being charged 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 $20 
copayment per day for days 1-20 of a benefit period, and $0 per day for days 21-100 of a benefit period. There 
were 28 days. For days 1-20, a $20 copayment. $20 x 20 = $400. Therefore, results in the total cost sharing 
amount of $400.  
 You have been asked to pay a $20 copayment per day for days 1-20 for skilled nursing facility (SNF) care. 
Skilled nursing facility (SNF) care falls within the skilled nursing facility (SNF) 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 skilled nursing facility (SNF) care on January 27, 2022, 
February 24, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on April 6, 
2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you are on a fixed income, 
and you cannot afford this bill. 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 one-way trip for Medicare covered ambulance services.  
 
You have been asked to pay $325 copayment for ambulance transport. Ambulance transport 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 transport 
provided on April 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an infusion of Zoldronic acid provided on 
February 9, 2022. 
 
You asked the Plan to waive the copayment for an infusion. You say that you've never had to pay a copayment 
for these infusions before. The Plan denied your request. The Plan says the copayment applied was 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 $30 
copayment for services obtained from a specialist, treatment by a nurse practitioner or physicians assistant or 
other non-physician health care professionals in a specialists office.  
 You have been asked to pay a $30 copayment for an infusion. An infusion falls within the Services Obtained 
from a Specialist, Treatment by a Nurse Practitioner or Physicians Assistant or Other Non-Physician Health 
Care Professionals in a Specialists Office 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 infusion of Zoldronic acid provided on February 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for injections provided on March 8, 2022, and 
March 17, 2022. 
 
You asked the Plan to waive the copayment for injections. You say that it was just a shot and its too 
expensive. The Plan denied your request. The Plan says the copayments applied are 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 $280 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges.  
 
 
 
 You have been asked to pay $560 ($280 x 2 visits) copayment for injections. Injections fall 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 injections provided 
on March 8, 2022, and March 17, 2022.