Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the radiation therapy services provided 
from January 10, 2022, to February 4, 2022. 
 
You asked the Plan to waive the coinsurance for the radiation therapy services. You say that you would like the 
Plan to adjust the claims and pay a greater share. The Plan denied your request. The Plan says the proper 
coinsurance 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 20% 
coinsurance for In-Network Radiation Therapy in a Specialist's Office. The first total amount allowed was 
$626.16 with a coinsurance amount of $125.23 ($626.16 x 20% coinsurance). The second total amount allowed 
was $1,508.55 with a coinsurance amount of $301.71 ($1,508.55 total amount x 20% coinsurance). The third 
amount allowed was $1,508.55 with a coinsurance amount of $301.71 ($1,508.55 total amount x 20% 
coinsurance). The fourth amount allowed was $1,005.70 with a coinsurance amount of $201.14 ($1,005.70 
total amount allowed x 20% coinsurance). The fifth total amount allowed was $1,193.74 with a coinsurance 
amount of $238.75 ($1,193.74 total amount allowed x 20% coinsurance). The sixth total amount allowed was 
$1,089.06 with a coinsurance amount of $217.81 ($1,089.06 total amount allowed x 20% coinsurance). The 
total coinsurance amount for the dates of services was $1,386.35 ($125.23 coinsurance + $301.71 coinsurance 
+ $301.71 coinsurance + $201.14 coinsurance + $238.75 coinsurance + $217.81 coinsurance). 
 
You have been asked to pay $1,386.35 coinsurance for the radiation therapy services. The radiation therapy 
services 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 coinsurance for the radiation therapy services provided from January 10, 
2022, to February 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the inpatient hospital services provided 
from December 20, 2021, to December 26, 2021. 
 
You asked the Plan to waive the coinsurance for the inpatient hospital services. You say that you were told 
your balance was less than what was billed. The Plan denied your request. The Plan says the benefit paid more 
than the out-of-network rate with less enrollee responsibility; therefore, the claim was processed 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% 
coinsurance for Out-of-Network Inpatient care in an Inpatient Hospital. The total allowed amount for the 
inpatient hospital services was $27,848.38 with a 40% coinsurance the coinsurance amount would be 
$11,139.35 ($27,848.38 total amount x 40% coinsurance). The total coinsurance amount charged by the Plan 
was $1,625 which is less than a 40% coinsurance amount of $11,139.35. 
 
  You have been asked to pay $1,625 coinsurance for the inpatient hospital services. The inpatient hospital 
services fall 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 coinsurance 
for the inpatient hospital services provided from December 20, 2021, to December 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a continuous positive airway pressure 
(CPAP) device provided from June 17, 2021, to March 17, 2022. 
 
You asked the Plan to waive the coinsurance for the CPAP device. You say that the machine gave you trouble 
and did not help. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment (DME), including oxygen equipment.  
 
You have been asked to pay $16.60 for each month, which is 20% of the allowed amount for the CPAP device 
($83.00 allowed amount x 20% coinsurance = $16.60). The total for all 10 months is $166.00 ($16.60 
coinsurance x 10 months = $166.00). The CPAP device falls within the Durable Medical Equipment (DME) 
and Related 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 
continuous positive airway pressure (CPAP) device provided from June 17, 2021, to March 17, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for colonoscopy provided on February 9, 2022. 
 
You asked the Plan to waive the copayment for colonoscopy. You say that this should be covered since no 
polyps were found. The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $325 
copayment for a surgical visit in a hospital if polyps were found during your screening. Since there is a history 
of polyps in the colon the colonoscopy is diagnostic.  
 
 
 You have been asked to pay $325 copayment for colonoscopy. Diagnostic colonoscopys fall within the 
Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for colonoscopy provided on 
February 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the 
lumbar spine provided on December 6, 2021. 
 
You asked the Plan to waive the copayment for the MRI. You say that you were not aware of the copayment at 
the time of service. 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 $250 
copayment per day for diagnostic radiology services that are not ultrasounds.  
 
You have been asked to pay $226.82, which is less than the $250 copayment for the MRI. The MRI falls within 
the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the lumbar spine provided 
on December 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravenous infusion services provided on January 17, 2022 
to January 31, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for intravenous infusion services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network 
and authorization is required prior to an out-of-network 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 intravenous infusion 
services provided on January 17, 2022 to January 31, 2022 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for a knee replacement procedure performed 
from November 17, 2021, to November 18, 2021. 
 
You asked the Plan to reduce the coinsurance for the knee replacement. You say that the enrollee should only 
have a $395 copayment for an outpatient visit. The Plan denied your request. The Plan says the correct 
coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a 20% coinsurance per visit for outpatient surgery.  
 
The enrollee has been asked to pay $2,635.77, which is 20% of the allowed amount for the knee replacement 
($13,178.86 allowed amount x 20% coinsurance = $2,635.77). The knee replacement falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers 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 reduce the coinsurance for a knee replacement procedure performed 
from November 17, 2021, to November 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 30, 2021. 
 
You asked the Plan to pay for the lab services. 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 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 the lab services provided on December 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on December 10, 2021. 
 You asked the Plan to pay for the services. The Plan denied your request. The Plan says genetic testing 
procedures submitted with code 81455 are unlikely to impact therapeutic decision-making in the clinical 
management of the patient. 
 
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 genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover 
this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
genetic testing services provided on December 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel (81455) 
provided November 15, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that this test is a proven medically necessary 
covered benefit. The Plan denied your request. The Plan says does not meet Medicare NCD/LCD criteria. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Genetic testing procedures submitted with code 81455 are unlikely 
to impact therapeutic decision-making in the clinical management of the patient and will be denied 
automatically as not medically necessary. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for the targeted genomic sequence analysis panel (81455) provided November 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
August 31, 2021. 
 
You asked the Plan to pay for dental services. You say that you were told that this dentist was in-network. The 
Plan denied your request. The Plan says services provided by an out-of-network provider are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers covered 
dental services when the services are provided by a participating provider. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for 
dental services provided by an out-of-network provider on August 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary. The Plan 
denied your request. The Plan says that the request for a home mechanical ventilator set in VAPS mode with 
Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a portable ventilator. Our reviewer says 
that a portable ventilator is not medically reasonable and necessary. There is no documentation that you have 
neuromuscular disease, thoracic restrictive disease or chronic respiratory failure consequent to chronic 
obstructive pulmonary disease. Provided records document that you have respiratory failure due to severe 
obstructive sleep apnea. Records do not document that you have tried and failed a bi-level positive airway pressure device. Records report tolerance to and benefit from bi-level positive airway pressure recently in the 
hospital setting. Our physician reviewer found that your condition does not meet Medicare criteria for a 
portable ventilator. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on April 12, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the anesthesia services. You say that you cannot obtain authorizations and the 
claim should be reprocessed and linked to the rendering facility. The Plan denied your request. The Plan says 
the rendering and referring providers are both OON providers and there was no approved authorization. Also, 
the service rendered was not urgent or emergent. 
 
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 anesthesia services provided on April 12, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an annual wellness visit provided on September 27, 
2021. 
 
You asked the Plan to waive the copayment for the wellness visit. You say that you were incorrectly charged 
for a wellness visit. The Plan denied your request. The Plan says that you have been charged the correct cost 
sharing amount. 
 
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. Specifically, the Plan did not submit the original appeal request, explanation of 
benefits, or medical records relevant to this case. Without this information, we are unable to verify the correct 
cost sharing amount, so we must find in your favor. Therefore, we decided that the Plan has to waive the 
copayment for an annual wellness visit provided on September 27, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 home health skilled nursing visits. 
 
You asked the Plan to pre-approve 2 home health skilled nursing visits. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 2 home health skilled nursing visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee 
does not have documented skilled nursing needs. As such, the requested, home health skilled nursing services 
are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 2 home health skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 2 home health skilled nursing visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for total hip joint replacement provided on 
December 10, 2021. 
 
You asked the Plan to waive the copayment for total hip joint replacement. You say that you are on a fixed 
income and cannot afford the copayment. The Plan denied your request. The Plan says the copayment applied 
is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $250 
copayment for per day for outpatient procedures and services.  
 
 You have been asked to pay $250 copayment for total hip joint replacement. Total hip joint replacement 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 
total hip joint replacement provided on December 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided on March 1, 2022. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you were never told there would be an 
additional charge for an x-ray and you feel it should be covered. The Plan denied your request. The Plan says 
the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $20 
copayment for each x-ray service.  
 
You have been asked to pay $20 copayment for an x-ray. 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 
an x-ray provided on March 1, 2022.