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

 
We decided that the Plan does not have to waive the deductible for the out-of-network transthoracic 
echocardiogram (TTE) with doppler provided on June 16, 2022. 
 
You asked the Plan to waive the deductible for the out-of-network transthoracic echocardiogram (TTE) with 
doppler. You say that the provider should be in-network. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $750 
deductible for outpatient diagnostic tests and therapeutic services and supplies (out-of-network). 
 
You have been asked to pay a $750 deductible for the out-of-network transthoracic echocardiogram (TTE) with 
doppler. This item/service falls within the outpatient diagnostic tests and therapeutic services and supplies (out-
of-network) 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. The file shows that the Plan verified the provider is not a network provider. Therefore, we decided that 
the Plan does not have to waive the deductible for the out-of-network transthoracic echocardiogram (TTE) with 
doppler provided on June 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient diagnostic tests provided on 
July 28, 2022. 
 
You asked the Plan to waive the copayment for the outpatient diagnostic tests. You say that you have never 
paid a copayment for these diagnostic test The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment for diagnostic procedures and tests at an outpatient hospital. 
 
You have been asked to pay a $100 copayment for the outpatient diagnostic tests. This item/service falls within 
the diagnostic procedures and tests at an outpatient hospital 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 outpatient diagnostic tests provided on July 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on June 13, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that you live on a limited income and cannot afford to 
pay additional costs for physicians that should not be required. The Plan denied your request. The Plan says eye 
refractions are only covered by your plan if performed by a participating provider and as a routine screening. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the eye refraction is performed during a routine exam. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that you did not receive a routine eye 
exam, but instead received a medical eye refraction for the diagnosis of Epithelial (juvenile) corneal dystrophy, 
bilateral. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not 
been met. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on 
June 13, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound on July 29, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment for an ultrasound.  
 
You have been asked to pay a $100 copayment for an ultrasound. This item/service falls within the Outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for an ultrasound on July 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99203) provided on April 4, 2022, by an out-
of-network provider. 
 
You asked the Plan to pay for an office visit. You say that the service should be covered, and you want the Plan 
to pay. The Plan denied your request. The Plan says the service sat issue is not a covered benefit.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
 
We looked at the file and the Plan's rules. The services were rendered out-of-network and is not covered. Based 
on this information, we decided that the Plan's rules for coverage of an office visit have not been met. 
Therefore, we decided that the Plan does not have to pay for an office visit (99203) provided on April 4, 2022, 
by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for dialysis on May 02, 2022, to May 31, 
2022. 
 
You asked the Plan to waive the coinsurance for dialysis. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for dialysis services in all places of service. Covered services include outpatient dialysis treatments 
(including dialysis treatments when temporarily out of the service area, as explained in Chapter 3). The 
provider billed in the amount of $96,831.80 and the allowed amount is $324.08. $324.08 x 20% = $64.82. 
There were 13 visits. $64.82 x 13 = $842.66. Therefore, results in the total cost sharing amount of $842.66.   
 
 
 
 
 You have been asked to pay a 20% coinsurance for dialysis. This item/service falls within the Services to treat 
kidney disease 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 dialysis on May 02, 2022, 
to May 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pulmonary testing provided on May 20, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the pulmonary testing. You say that the services were medically necessary. The 
Plan denied your request. The Plan says a referral/authorization was not obtained prior to services being 
rendered. 
 
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 pulmonary testing provided on May 20, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care visit provided on July 09, 
2022. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that they were unable to resolve 
the issue. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for urgently needed services. 
 
You have been asked to pay a $40 copayment for the urgent care visit. This item/service 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 the urgent 
care visit provided on July 09, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 14, 2022 to 
February 15, 2022, by an OON provider. 
 
You asked the Plan to pay for laboratory services. You say that you say that this service does not require a prior 
authorization. The Plan denied your request. The Plan says the out-of-network services were not 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 laboratory services provided on February 14, 2022 
to February 15, 2022, by OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for light compression bandages provided on May 11, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for light compression bandages. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the provider is out-of-network, and it 
was determined these services can be received in-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 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 light compression bandages provided on May 11, 
2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for x-rays and office visit on April 29, 2022. 
 
You asked the Plan to waive the copayments for x-rays and office visit. You say that you state that you are not 
paying the $50 or $35 copayment. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for each Medicare-covered x-ray. Covered services include but are not limited to x-rays. You must 
pay a $35 copayment for physician specialist services (including surgery second opinion, telehealth services, 
home infusion professional services, and urgently needed services). Covered services include consultation, 
diagnosis, and treatment by a specialist. $50 + $35 = $85. Therefore, results in the total cost sharing amount of 
$85.   
You have been asked to pay a $50 copayment for x-rays and a $35 copayment for office visit. This item/service 
falls within the Outpatient diagnostic tests and therapeutic services and supplies and 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 x-rays and office visit on April 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient mental health care provided 
on April 22, 2022, to April 29, 2022. 
 
You asked the Plan to waive the copayment for the inpatient mental health care. You say that the services were 
medically necessary. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copayment for inpatient mental health care. 
 
You have been asked to pay a $150 copayment for the inpatient mental health care. This item/service falls 
within the inpatient mental health 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 
the inpatient mental health care provided on April 22, 2022, to April 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a therapeutic continuous glucose monitor 
(cgm) and a receiver monitor provided on July 17, 2022. 
 
You asked the Plan to waive the coinsurance for a therapeutic continuous glucose monitor (cgm) and a receiver 
monitor. You say that you were told this would be covered in full due to the plan you have. The Plan denied 
your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 10% 
coinsurance for Medicare covered diabetic supplies.  
 
 
  You have been asked to pay $52.16 in coinsurance, which is 10% of the allowed amount for a therapeutic 
continuous glucose monitor (cgm) ($521.61 x 10% = $52.16). You have also been asked to pay $18.29 in 
coinsurance, which is 10% of the allowed amount for a receiver monitor ($182.90 x 10% = $18.29). These 
items fall within the Medicare covered diabetic 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 coinsurance for a therapeutic continuous glucose monitor (cgm) and a receiver monitor provided on July 
17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for  a cystoscopy procedure and bladder lesion 
treatments provided from April 26, 2022, to May 25, 2022. 
 
You asked the Plan to waive the copayment for  a cystoscopy procedure and bladder lesion treatments. You say 
that you are requesting a reconsideration of the copayment. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment per visit, for outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
 
You have been asked to pay a total of $834.02 copayment for a cystoscopy procedure and bladder lesion 
treatments. For the cystoscopy on date of service of April 26, 2022, the total amount allowed was $577.27 with 
a copayment amount of $300. For the bladder lesion on treatments on dates of service of May 18, 2022, and 
May 25, 2022, the total amount allowed was $267.01, which is less than the copayment amount of $300. The total copayment amount for all dates of service was $834.02 ($267.01 copayment amount + $267.01 
copayment amount + $300 copayment amount). These services fall within the surgery services provided in an 
outpatient hospital. 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 cystoscopy procedure and 
bladder lesion treatments provided from April 26, 2022, to May 25, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services on June 25, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you would like to 
appeal the cost share. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 
copayment for emergency room services.  
 
You have been asked to pay a $120 copayment for emergency room services. This item/service 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 emergency room services 
on June 25, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy on March 14, 2022, to 
March 28, 2022. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you should not owe because the 
provider did not tell you about the copay. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for Medicare-covered therapy visits. Covered services include physical therapy, occupational 
therapy, and speech language therapy. There were 4 visits. 4 x $35 = $140. Therefore, resutls in the total cost 
sharing amount of $140. 
 
 
 
 
 You have been asked to pay a $35 copayment for each physical therapy. This item/service falls 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 on March 14, 2022, to March 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 19, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined 
these services can be received in-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 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 an office visit provided on July 19, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for cardiovascular services provided on May 
11, 2022. 
 
You asked the Plan to waive the coinsurance for cardiovascular services. You say that the provider directory 
was published on January 12, 2022. You say three months thereafter, you made and appointment with the 
cardiologist listed in the provider book. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 30% 
coinsurance for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay 30% coinsurance for cardiovascular services. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan.  Therefore, we decided that the Plan does not have 
to waive the coinsurance for cardiovascular services provided on May 11, 2022.