Persius/hicric huggingface dataset:
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 April 8, 
2022. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you would like the 
copayment waived. The Plan denied your request. The Plan says the proper copayment was applied for the 
service that was rendered. 
 
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 $45 
copayment for in-network specialist's office visits.  
 
You have been asked to pay a $45 copayment for the specialist office visit. The 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 April 8, 2022.  
 Your complaint about your enrollment into the Plan is not a valid appeal for medical coverage. This part of 
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mammography provided on March 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the mammography. You say that you were unaware that the provider was OON 
and you thought the service would be covered. The Plan denied your request. The Plan says the claim 
processed correctly because the rendering provider is an OON provider. 
 
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 mammography provided on March 1, 2022, by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for cataract surgery provided on May 22, 
2019. 
 
You asked the Plan to waive the coinsurance for cataract surgery. You say that you feel the plan misled you, 
and that this cost is too high. 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 out-of-network Medicare-covered outpatient surgery or procedure at an outpatient department 
of a hospital. The allowed amount of this surgery is $2667.40, resulting in a coinsurance amount of $533.48 
($2667.40 x 20% = $533.48). 
 You have been asked to pay a $533.48 coinsurance for cataract surgery. Cataract 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 coinsurance for cataract 
surgery provided on May 22, 2019.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on October 29, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the ordering physician requested the test to 
be conducted. The Plan denied your request. The Plan says that the rendering provider is an OON provider and 
the service rendered was not urgent or emergent. 
 
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 laboratory request form and face sheet form submitted lists an ordering 
physician. The Plan did not submit documentation supporting that the ordering physician is also out-of-
network. Therefore, we decided that the Plan has to pay for the laboratory services provided on October 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 10, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial observation care provided on April 7, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for initial observation care. You say that the services provided to the patient were a 
medical necessity. The Plan denied your request. The Plan says this provider is not a network provider with the 
Plan. The Plan also says that the services were not referred by a network provider or rendered in an in-network 
facility. The Plan also says that the services were not approved in advance. 
 
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 initial observation care provided on April 7, 2022, 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dermatology services provided on May 9, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you were told the provider was in-network. 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 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. The Plan researched your contact history and found no documentation that you contacted 
them regarding this providers network status. 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 dermatology services 
provided on May 9, 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 a denosumab injection provided on 
February 18, 2022. 
 
You asked the Plan to waive the coinsurance for a denosumab injection. You say that you were told when you 
signed up for the Plan that your injections would still be covered at 100% just like it always was. The Plan 
denied your request. The Plan says you were 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 Medicare Part B prescription drugs.  
 
 
 
 
 
 
 You have been asked to pay $254.52 in coinsurance, which is 20% of the allowed amount for a denosumab 
injection ($1,272.60 allowed amount x 20% coinsurance = $254.52). A denosumab 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 a 
denosumab injection provided on February 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for anesthesia services provided on May 18, 
2022. 
 
You asked the Plan to waive the coinsurance for anesthesia services. You say that you had no idea that the 
anesthesia provider would be an out-of-network provider. You also say that you were not given the choice of 
which anesthesiologist would perform your service. The Plan denied your request. The Plan says you were 
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 50% 
coinsurance for out of network colorectal cancer screening.  
 
 
 
 
 
 You have been asked to pay $66.91 in coinsurance, which is 50% of the allowed amount for anesthesia services 
($133.83 x 50% = $66.92). Anesthesia services fall within the out of network colorectal cancer screening 
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 anesthesia services provided on 
May 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on April 28, 
2022. 
 
You asked the Plan to waive the copayment for laboratory services. You say that this service should have been 
included in the copayment for his May 6, 2022, office visit. The Plan denied your request. The Plan says you 
were 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 $10 
copayment per day for other Medicare-covered laboratory tests that are not fecal immunochemical tests (FIT 
tests).  
 
 
 
 You have been asked to pay a $10 copayment for laboratory services. Laboratory services 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 laboratory services provided on April 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 20, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. 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 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 January 20, 
2022 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
heart provided on May 10, 2022. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you called the Plan a couple of months 
ago and was told there would be no copayment for this, and you got a bill for $97.44 The Plan denied your 
request. The Plan says you were 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 $300 
copayment for other outpatient diagnostic tests such as a computed tomography.  
 
 
 
 
 
 
 You have been asked to pay $97.44, which is less than the $300 copayment for a CT scan of the heart. A CT 
scan falls within the other outpatient diagnostic tests such as a computed tomography 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 computed tomography (CT) scan of the heart provided on 
May 10, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency transport ambulance service 
provided on May 14, 2021. 
 
You asked the Plan to waive the copayment for emergency transport ambulance service. You say that your 
ambulance ride was awful and do not feel the insurance should pay for anything. The Plan denied your request. 
The Plan says you were 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 $275 
copayment for each one-way Medicare-covered trip.  
 
 
 
 
 
 
 You have been asked to pay a $275 copayment for emergency transport ambulance service. emergency 
transport ambulance service falls within the for each one-way Medicare-covered trip 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 transport ambulance service provided on May 
14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a targeted genomic sequence analysis panel, solid organ 
neoplasm, cell-free DNA, analysis of 311 or more genes, interrogation for sequence variants (0239U) provided 
on March 1, 2022. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee was diagnosed with advanced cancer. 
You received an order by the treating physician because the test results were needed to help determine 
the course of treatment for the patient. You performed and reported the results to the treating physician which 
are medically necessary. The Plan denied your request. The Plan says we cannot determine how the enrollee 
came to the servicing provider, or whether the services are medically necessary. 
 
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 0239U is not supported in the medical record. Specifically, we did not receive 
documentation supporting the reason for the testing, if the services were medically necessary or how the 
enrollee came to the servicing provider. There is no referral on file. The records show that the Plan attempted to 
obtain this information, but it was not received. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for a 
targeted genomic sequence analysis panel, solid organ neoplasm, cell-free DNA, analysis of 311 or more genes, 
interrogation for sequence variants (0239U) provided on March 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
abdomen provided on April 8, 2022. 
 
You asked the Plan to waive the copayment for a CT scan of the abdomen. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says you were 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 $245 
copayment for Medicare-covered diagnostic radiology services (CT scans).  
 
You have been asked to pay a $245 copayment for a CT scan of the abdomen. a CT scan of the abdomen falls 
within the Medicare-covered diagnostic radiology services (CT scans) 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 computed tomography (CT) scan of the abdomen provided on 
April 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
March 31, 2022, to April 4, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you would like the Plan 
to waive the copayment because you cannot afford the amount. The Plan denied your request. The Plan says 
the proper copayment was applied for the service that was billed. 
 
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 $315 
copayment per day for each Medicare-covered hospital stay, for days 1-7. The total copayment amount charged 
was $1,260 ($315 per day x 4 days). 
 
  You have been asked to pay a $1,260 copayment for the inpatient hospital stay. The 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 
an inpatient hospital stay provided from March 31, 2022, to April 4, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance on March 23, 2022. 
 
You asked the Plan to waive the copayment for ambulance. 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 $317 
copayment for Medicare-covered ambulance transport (one-way). Covered ambulance services include fixed 
wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that can provide care if 
they are furnished to a member whose medical condition is such that other means of transportation could 
endanger the persons health or if authorized by the plan.  
 
You have been asked to pay a $317 copayment for ambulance. Ambulance 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 on March 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on June 03, 2022. 
 
You asked the Plan to waive the copayment for office visit. 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 $50 
copayment for provider and professional services at specialists office. Covered services include consultation, 
diagnosis, and treatment by a specialist.  
 
You have been asked to pay a $50 copayment for office visit. Office visits fall 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 office visit on June 03, 2022.