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

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on February 
24, 2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you feel you are not 
responsible for the $275 copayment. You say you can't afford to pay on your income. The Plan denied your 
request. The Plan says you have been charged the correct copayment 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 $275 
copayment per one way trip for emergency and non-emergency ambulance services.  
 
 
 
 
 
 You have been asked to pay a $275 copayment for ambulance transport. The 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 February 24, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided from 
January 7, 2022 to January 9, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you feel you should not 
be responsible for the copayment because you were admitted to the facility. The Plan denied your request. The 
Plan says you have been charged the correct copayment 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 per visit. Copayment not waived if admitted to hospital.  
 
You have been asked to pay a $90 copayment for an emergency room visit. The emergency room visit falls 
within the Emergency care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an 
emergency room visit provided from January 7, 2022 to January 9, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
from December 3, 2020, to December 23, 2020. 
 
You asked the Plan to waive the copayment for the SNF care. You say that the provider should have notified 
insurance of the extra days. You say you should not be held responsible. 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 $0 per 
day for days 1-20 and $25 per day for days 21-100 for each benefit period. 
 
 
 Dates of Service Benefit Days Copayment 
November 13, 2020  December 2, 2020 1-20 $0/day 
December 3, 2020  December 23, 2020 21-40 $25/day 
Total:  $500 
 
You have been asked to pay $25 per day for days 21-40 for the SNF care, for a total of $500. The 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 provided from December 3, 2020, to December 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telephone evaluation and management service, a 
pneumococcal vaccine, and patient screened for future fall risk provided on January 5, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a telephone evaluation and management service, a pneumococcal vaccine, and 
patient screened for future fall risk. You say that you were unaware and have not received any letters from the 
Plan saying that the provider is no longer in-network for the new year of 2022, and if you were aware, you 
would not have gone to that provider. The Plan denied your request. The Plan says this provider is no longer in 
your network as a primary care physician, and there are other primary care physicians in-network in your area. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a telephone evaluation and management service, a 
pneumococcal vaccine, and patient screened for future fall risk provided on January 5, 2022, by an out-of-
network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
September 9, 2021. We also decided that the Plan does not have to waive the copayments for emergency room 
(ER) visits provided on September 9, 2021, and September 13, 2021. 
 
You asked the Plan to waive the copayments for the ambulance transportation and ER visits. You say that the 
ambulance would not take you to the requested hospital. You say the hospital did not have a cardiologist on 
call. 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 $295 copayment for each one-way ambulance trip. 
 
Your contract with the Plan also clearly says that you must pay a $90 copayment for emergency care. 
 
You have been asked to pay a $295 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance Services benefit category. You have also been asked to pay a $90 copayment for 
each of the ER visits. The ER visits fall within the Emergency Care benefit category. The total for all services 
is $475. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
September 9, 2021. We also decided that the Plan does not have to waive the copayments for emergency room 
(ER) visits provided on September 9, 2021, and September 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on January 4, 2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that no exam was performed. You say 
that you received a COVID-19 test and then you went home. The Plan denied your request. The Plan says you 
have been charged the correct copayment amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for each Medicare-covered urgent care facility visit. The copayment is not waived if you are 
admitted as an inpatient to the hospital within 24 hours for the same condition.  
 
 You have been asked to pay a $50 copayment for an office visit. The office visit falls within the Urgently 
needed 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 an office visit 
provided on January 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a rheumatology specialist office visit 
provided on January 28, 2022. 
 
You asked the Plan to waive the cost share for a specialist office visit. You say that this visit should be 
processed as an in-network primary care visit. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay 40% coinsurance for an out-of-network specialist office visit.  
 
The record shows the provider is an out-of-network specialist. The enrollee has been asked to pay $33.58, 
which is 40% coinsurance of the allowed amount for a specialist office visit ($83.95 allowed amount x 40% coinsurance = $33.58). A specialist office visit falls within the Physician/Practitioner Services, Including 
Doctors Office Visits 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 cost share for a 
rheumatology specialist office visit provided on January 28, 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 December 30, 
2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that your office visit should be 
covered. The Plan denied your request. The Plan says the copayment was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for each Medicare-covered podiatry visit.  
 
You have been asked to pay a $30 for the office visit. The office visit falls 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 copayment for the office visit provided on 
December 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an at-home COVID-19 test received on January 6, 2022. 
 
You asked the Plan to pay for the test. You say that this was medically necessary. The Plan denied your 
request. The Plan says this was not covered until 2/1/22. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered.  
The test at issue in this appeal, the test, was requested solely for screening purposes. Medicare does not cover 
this test solely for screening purposes before 2/1/22. Therefore, we decided that the Plan does not have to pay 
for an at-home COVID-19 test received on January 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a specialist office visit and diffuse 
capacity test provided on December 17, 2021. 
 
You asked the Plan to waive the copayments for the office visit and diffuse capacity test. You say that you 
were not aware of the separate copayment for the test. The Plan denied your request. The Plan says you have 
been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for each specialist visit.  
 
You have been asked to pay a $50 copayment for the office visit. The office visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. You have also been asked to pay a $25 copayment for the diffuse capacity test. The diffuse capacity test falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. The total for the visit is $75. 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 a specialist office visit and diffuse capacity test provided 
on December 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy (chemo) provided on 
January 31, 2022. 
 
You asked the Plan to waive the coinsurance for the chemo. You say that you were told you would only be 
responsible for a copay. The Plan denied your request. The Plan says the coinsurance was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for in-network Medicare Part B drugs, including chemotherapy drugs. 
 
 
  You have been asked to pay $2,974.48 for the chemo. Chemotherapy (chemo) 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 
chemotherapy (chemo) provided on January 31, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound received on June 7, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that if you were told you would have to 
pay for the ultrasound you wouldn't have had it done. The Plan denied your request. The Plan says the 
copayment was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $150 
copayment for Medicare-covered radiological diagnostic services, not including X-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic).  
 
 
  You have been asked to pay the allowed amount of $121.73 for the ultrasound which is less than the standard 
$150 copayment. The 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 
the ultrasound received on June 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for catheter supplies provided on January 28, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for catheter supplies. You say that you would like to appeal the denial of the claim 
and that you switched catheter suppliers because the new supplier was less expensive. The Plan denied your 
request. The Plan says the member used a supplier that is not enrolled in Medicare and the plan does not cover 
non-Medicare providers unless authorized. 
 
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 catheter supplies provided on January 28, 2022 by 
an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy service rendered by the out-of-network 
(OON) provider on February 8, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the psychotherapy service rendered by the out-of-network (OON) provider on 
February 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 29, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this was reported correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for laboratory services provided to the enrollee on April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204), the x-ray of the bladder/urethra 
(74450), and the injection for the bladder x-ray (51610) rendered by the out-of-network (OON) provider on 
January 3, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. 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 the office visit (99204), the x-ray of the bladder/urethra (74450), and the injection 
for the bladder x-ray (51610) rendered by the out-of-network (OON) provider on January 3, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says you do not meet the Medicare criteria for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that you do not have daily skilled nursing 
needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 
skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services provided to the enrollee from December 2, 
2021, to December 13, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this code has a status indicator of B. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 97010 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 97010 is not separately payable. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for therapy services 
provided to the enrollee from December 2, 2021, to December 13, 2021.