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

 
We decided that the Plan does not have to waive the copayment for outpatient hospital surgery provided on 
November 18, 2021. 
 
You asked the Plan to waive the copayment for outpatient hospital surgery. You say that you thought there 
would be a $0 copayment for the services. The Plan denied your request. The Plan says the copayment amount 
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 $300 
copayment for surgery services provided at an outpatient hospital facility.  
 
 
 You have been asked to pay a $300 copayment for outpatient hospital surgery. Outpatient hospital surgery falls 
within the Outpatient Hospital Services benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for outpatient hospital surgery provided on November 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the cataract surgery (66984) provided on 
August 5, 2020 and August 19, 2020. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295  
copayment for outpatient surgery at an ambulatory surgical center.  
 
 
 You have been asked to pay $590 ($295 copayment x 2) for the outpatient surgeries provided at an ambulatory 
surgical center. 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 the cataract surgery (66984) provided on 
August 5, 2020 and August 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to lower the copayment for an x-ray provided on December 14, 2021. 
 
You asked the Plan to lower the copayment for an x-ray. You say that your copayment should be lower than 
what was charged. The Plan denied your request. The Plan says the enrollee did not hit their yearly deductible 
prior to the date of service. Therefore, the proper deductible and copayment was applied. 
  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible which applies to this is the amount you have to pay 
out-of-pocket before we will pay our share for your covered medical services. Until you have paid the 
deductible amount, you must pay the full cost of your covered services. Once you have paid your deductible, 
we will begin to pay our share of the costs for covered medical services and you will pay your copayment or 
coinsurance amount for the rest of the calendar year. Prior to the date of service, the total amount paid towards 
the yearly deductible was $706.60 leaving $43.40 ($750 yearly deductible - $706.60 paid towards deductible) 
as the remaining balance of the yearly deductible. Therefore, the deductible amount paid towards the x-ray was 
$43.40. 
 
Your contract with the Plan clearly says that you must pay a $15 copayment for each Medicare-covered 
standard X-ray service. The total amount allowed for the x-ray was $43.45. With the deductible of $43.40 paid 
towards the total amount of $43.45 leaving $.05 ($43.45 total amount - $43.40 deductible paid). Therefore, 
only $.05 was charged as the copayment since it is less than the copayment amount of $15. 
 
You have been asked to pay a $43.40 deductible and a $.05 copayment for the x-ray. The x-ray 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 lower the copayment for an x-ray provided on December 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a video phone. 
 
You asked the Plan to pre-approve the phone. You say that this is needed due to hearing and voice loss. The 
Plan denied your request. The Plan says this does not meet the definition of durable medical equipment. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a video phone.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 
20, 2021. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 20, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic treatments provided on November 1, 2021, to 
November 9, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for chiropractic treatments. You say that you are resubmitting the claim because the 
bills had the wrong codes when last submitted. The Plan denied your request. The Plan says the provider is out-
of-network. 
 
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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for chiropractic treatments provided on November 1, 2021, to 
November 9, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for inpatient hospital care provided from 
October 20, 2021, to October 25, 2021. 
 
You asked the Plan to waive the deductible for the inpatient care. You say that the visit was due to COVID-19. 
The Plan denied your request. The Plan says the correct amount was applied to your deductible and the correct 
cost sharing amount was charged. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $1,000 deductible which applies to certain items and services. 
 The item or service you asked the Plan to waive the deductible and copayment for falls within the Inpatient 
Hospital Care benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is $1,000 deductible which applies to certain items and services. This cost sharing is a contractual 
obligation that had not been met at the time the inpatient care was received from October 20, 2021, to October 
25, 2021. Therefore, we decided that the Plan does not have to waive the deductible for inpatient hospital care 
provided from October 20, 2021, to October 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance ground service provided on 
October 24, 2021. 
 
You asked the Plan to waive the copayment for the ambulance ground service. You say that you should have 
been charged a 20% coinsurance. The Plan denied your request. The Plan says the copayment amount 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 $265 
copayment for each Medicare-covered, one-way ground ambulance trip.  
 
 You have been asked to pay a $265 copayment for the ambulance ground service. Ambulance ground service 
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 
the ambulance ground service provided on October 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for X-rays of the neck and spine provided on 
December 7, 2021. 
 
You asked the Plan to waive the copayment for the X-rays. You say that you disagree with the charges. 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 an $85 
copayment for X-rays at any location other than your PCP's office.  
 
You have been asked to pay an $85 copayment for the X-rays. The X-rays fall within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for X-rays of the neck and spine provided on December 7, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit provided on October 1, 2021 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the enrollee was seen by a primary care physician at 
a rural health clinic and referral is not needed. The Plan denied your request. The Plan says that the services 
were provided out-of-network and were not approved in advance. 
 
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 did not submit medical records, nor any attempts to obtain medical 
records. Without records, we cannot determine whether the enrollee met the Medicare criteria for urgent out-of-
area treatment. Therefore, we decided that the Plan has to pay for the office visit provided on October 1, 2021 
by an out-of-network (OON) provider.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for bevacizumab-awwb injections provided 
from December 2, 2021, to January 19, 2022. 
 
You asked the Plan to review the coinsurance for the bevacizumab-awwb injections. You say that you were not 
aware that you had such large copayments and I want to make sure the provider is using the correct current 
procedural terminology (CPT) codes when they are billing. You also say that you do not think 20% 
coinsurance is correct. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Part B drugs.  
 
The record shows these claims were approved, and you have a cost sharing amount. You have been asked to 
pay a total of $1,031.92, which is 20% coinsurance for each bevacizumab-awwb injection. 
 
Date of Service Allowed Amount 20% Coinsurance 
 
Claim #: KQ306127120211202   
December 2, 2021 $1,363.17 $272.63 
December 20, 2021 $1363.17 $272.63 
 
Claim #: KV380367120220103   
January 3, 2022 $1,216.66 $243.33 
January 19, 2022 $1,216.66 $243.33 
Total   $1,031.92 
 
A bevacizumab-awwb 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 bevacizumab-awwb injections provided from December 2, 
2021, to January 19, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing test provided on August 26, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for hearing test. You say that you would like to appeal the denial of the claim. The 
Plan denied your request. The Plan says prior authorization is required for an out-of-network office visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for hearing test provided on August 26, 2021 by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on December 2, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that the services were referred by the enrollee's physician. 
The Plan denied your request. The Plan says the denial of payment for this service is correct, because this 
provider is out-of-network with the Plan and the ordering physician was also out-of-network with the Plan. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for drug testing provided on December 2, 2021 by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the otolaryngology specialist office visits 
provided on January 7, 2022, and January 25, 2022. 
 
You asked the Plan to waive the copayments for the specialist office visits. You say that you had bleeding after 
having your ears cleaned and had to have two visits after that. You also say that you do not think you should 
have to pay the two separate $35 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 specialist office visit.  
 
 The record shows these claims were approved, and you have a cost sharing amount. You have been asked to 
pay a $35 copayment for each specialist office visit on January 7, 2022, and January 25, 2022. A specialist 
office visits 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 copayments for the otolaryngology specialist office visits provided on 
January 7, 2022, and January 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 
19, 2021. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 19, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient hospital admission. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the inpatient admission is 
medically necessary. The Plan denied your request. The Plan says the patient can be managed in an outpatient 
setting. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient care are met.  Our physician reviewer found the record does not show that the admitting physician reasonably expected that 
the patient's necessary hospital care would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an inpatient hospital admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you an additional amount for a gym membership provided 
on January 1, 2021. 
 
You asked the Plan to reimburse you an additional amount for a gym membership. The Plan denied your 
request. The Plan says you were reimbursed $150.00 in January 2022 towards this amount. You had reached 
the maximum allowed reimbursed amount for the 2021 calendar year. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 We looked at the file and the Plans rules. The file shows you were reimbursed $150.00 in January 2022 
towards this amount. You had reached the maximum allowed reimbursed amount for the 2021 calendar year. 
Therefore, we decided that the Plan does not have to reimburse you an additional amount for a gym 
membership provided on January 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services you provided on January 19, 2022. 
 
You asked the Plan to pay for physician's services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that the Plan will not cover care from a provider who does not work 
with the health Plan unless one of the following situations applies: emergency or urgently needed services 
when the network is not available, out of area dialysis services, and cases in which the Plan authorizes use of 
out-of-network providers. None of these situations outlined in the Evidence of Coverage apply to provide 
coverage for the out of network care. There are contracted providers available within the time and distance 
standards set forth by Medicare to provide the services. 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services you provided on January 19, 2022.