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

 
We decided that the Plan does not have to reduce the coinsurance for a prescription drug injection provided on 
March 30, 2022. 
 
You asked the Plan to reduce the coinsurance for a prescription drug injection. You say that you were charged 
a different amount for the same service. You say that you believe there may be an issue with the way the 
service was billed. The Plan denied your request. The Plan says the coinsurance amount 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 20% 
coinsurance for Medicare Part B prescription drugs. The allowed amount of the claim is $381.36, resulting in a 
coinsurance amount of $76.27 (381.36 x 20%). 
 
You have been asked to pay $76.27 for a prescription drug injection. A prescription drug 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 reduce the coinsurance for a prescription drug injection provided on 
March 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on  
March 2, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that this was a follow-up visit 
and should be within the global period. 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 $35 
copayment for each in-person specialist visit. 
 
You have been asked to pay a $35 copayment for a specialist office visit. A specialist office visit falls within 
the Physician/Practitioner Services, Including Doctor's 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 specialist office visit provided on March 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections provided on March 1, 2022. 
 
You asked the Plan to waive the coinsurance for injections. You say that you should not have a coinsurance for 
this. Just a regular copayment. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for Medicare Part B prescription drugs. The allowed amount of this drug is $1,079.04, resulting in 
a coinsurance amount of $215.81 ($1,079.04 x 20% = $215.81). 
 
You have been asked to pay a $215.81 coinsurance for injections. Injections fall within the Medicare Part B 
Prescription Drugs benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for injections provided 
on March 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injection on February 16, 2022. 
 
You asked the Plan to waive the coinsurance for injection. 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 20% 
coinsurance for Medicare-covered Part B medications, including, but not limited to, chemotherapy and drugs 
used during outpatient diagnostic procedures. These drugs are covered under Part B of Original Medicare. 
Members of our plan receive coverage for these drugs through our plan. Covered drugs include drugs that 
usually arent self-administered by the patient and are injected or infused while you are getting physician, 
hospital outpatient, or ambulatory surgical center services.  The provider billed in the amount of $63 and the 
allowed amount is $6.04. Therefore, results in the total cost sharing amount of $6.04. 
 
 
 You have been asked to pay a $6.04 coinsurance for injection. 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 injection on 
February 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a specialist office visit provided on 
January 18, 2022. 
 
You asked the Plan to waive the coinsurance for the specialist visit. You say that you were under the 
impression that this visit was only for a wellness check. The Plan denied your request. The Plan says the 
correct coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 10% 
coinsurance for doctor visits.  
 
The records show that during the wellness visit, a PAP smear was also conducted. This test goes beyond the 
scope of the wellness exam. Therefore, you have been asked to pay $8.81, which is 10% of the allowed amount 
for the specialist visit ($88.10 allowed amount x 10% coinsurance = $8.81). The specialist visit falls within the 
Doctor and Other Health Care Provider 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 a specialist office visit provided on January 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of 
lower extremity provided on July 24, 2021. 
 
You asked the Plan to waive the copayment for the MRI. You say that you were under financial aid and the 
Plan never said that you were not still. You say you cannot afford the cost of this fee. 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 $150 
copayment for an MRI.  
 
You have been asked to pay a $150 copayment for the MRI. The MRI 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 magnetic resonance imaging (MRI) of lower extremity provided on July 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a coronary catheter placement performed 
on February 23, 2022. 
 
You asked the Plan to reduce the copayment for the catheter placement. You say that you were informed that 
the copayment would only be $150 at the hospital 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 $290 
copayment for each ambulatory surgical center or outpatient hospital visit.  
 
You have been asked to pay a $290 copayment for the catheter placement. The catheter placement 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 a coronary catheter 
placement performed on February 23, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
December 2, 2021. 
 
You asked the Plan to waive the copayment for the PT services. You say that you cannot afford all of the 
copayments. 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 $35 
copayment for each physical therapy visit.  
 You have been asked to pay a $35 copayment for the PT services. The PT 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 (PT) services provided on December 2, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the subsequent hospital care (99232) services provided on November 
29, 2021. 
 
You asked the Plan to pay for code 99232. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan says the claim denied correctly as the Health Care Financing 
Administration (HCFA) form was submitted with the dates of November 28, 2021, to November 29, 2021, for 
line 2 (99232). However, the file shows that there is a corrected HCFA form that shows line 2 was corrected 
with only the November 29, 2021, date of service for code 99232. The Plan has provided no other rationale for 
their denial of payment based on Medicare guidelines. Therefore, we decided that the Plan has to pay for the 
subsequent hospital care (99232) services provided on November 29, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the copayment for an emergency room (ER) visit 
provided on March 4, 2022. 
 
You asked the Plan to waive or reduce the copayment for the ER visit. You say that the infusion could only be 
done at the ER instead of a clinic. 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 $90 
copayment for each emergency room visit.  
 
You have been asked to pay a $90 copayment for the ER visit. The ER 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 or reduce the copayment for an emergency room 
(ER) visit provided on March 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 14, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 
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 laboratory services provided on April 14, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a joint injection provided on April 7, 2022. 
 
You asked the Plan to reduce the copayment for the injection. You say that you feel the visit should be 
classified as an office visit with a lower copayment. 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 $375 
copayment for surgery or services at an outpatient hospital.  
 
You have been asked to pay $306.44, which is less than the $375 copayment for the injection. The injection is 
considered a surgical procedure and 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 a joint injection provided on April 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the liver elastography provided on February 
18, 2022. 
 
You asked the Plan to waive the cost share for the liver elastography. You say that you say that you are 
appealing this cost-sharing. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for non-radiological diagnostic services.  
 
You have been asked to pay a 20% coinsurance for the liver elastography for a total of $6.07. The liver 
elastography 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 cost share for the liver elastography provided on February 18, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on April 19, 2022, to 
April 22, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. 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 $325 
copayment per day, days 1-5; $0 per day, days 6-90; $0 copay for additional days for inpatient services. 
Includes inpatient acute, inpatient rehabilitation, long-term care hospitals and other types of inpatient hospital 
services. Inpatient hospital care starts the day you are formally admitted to the hospital with a doctors order. 
The day before you are discharged is your last inpatient day. There were 3 days. $325 x 3 = $975. Therefore, 
results in the total cost sharing amount of $975.   
 
 
 You have been asked to pay a $325 copayment per day for inpatient hospital stay. Inpatient hospital stay falls 
within the Inpatient hospital care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
inpatient hospital stay on April 19, 2022, to April 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Part B drug on March 24, 2022. 
 
You asked the Plan to waive the coinsurance for Part B drug. 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 20% 
coinsurance for each Medicare-covered Part B drug. These drugs are covered under Part B of Original 
Medicare. Members of our plan receive coverage for these drugs through our plan. Covered drugs include 
Drugs that usually arent self-administered by the patient and are injected or infused while you are getting 
physician, hospital outpatient, or ambulatory surgical center services. The provider billed in the amount of 
$683 and the allowed amount is $394.12. $394.12 x 20% = $78.82. Therefore, results in the total cost sharing 
amount of $78.82. 
 
 
 
 You have been asked to pay a 20% coinsurance for Part B drug. Part B drug 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 Part B drug on 
March 24, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on June 16, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that this is not your responsibility as 
you already paid a copayment. 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 $20 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay the allowed amount of $14.30, which is less than the $20 copayment for an 
ultrasound. An 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 ultrasound provided on June 
16, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Nexplanon Implant 68mg. 
 
You asked the Plan to pay for a Nexplanon Implant. You say that the enrollee does not wish to become 
pregnant at this time. You also say that the implant is tolerated well by the enrollee. The Plan denied your 
request. The Plan says the Nexplanon contraceptive implant is a contraceptive device, and is excluded from 
coverage. 
 
The Plan must follow Medicare rules. The rules say that items/services for the purposes of preventing 
conception (contraception) are not considered medically reasonable and necessary.  
 
Records show that the requested service is primarily for the purpose of contraception. The documentation does 
not show that this service is being requested to treat a specific illness/injury. As such, the Medicare rules for 
coverage of this item/service have not been met. Therefore, we decided that the Plan does not have to pay for a 
Nexplanon Implant 68mg.