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

 
We decided that the Plan does not have to waive the coinsurance for the injections received on February 23, 
2021, and January 28, 2022. 
 
You asked the Plan to waive the coinsurance for the injections. You say that the coinsurance is a lot of money, 
and you feel that they should be covered. The Plan denied your request. The Plan says the coinsurance 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% 
coinsurance for Medicare Part B chemotherapy prescription drugs and non-chemotherapy prescription drugs.  
  You have been asked to pay a total of $1,117.72 for the injections.  
 
Date of Service Service Allowed Amount Coinsurance Member Liability 
02/23/2021 Denosumab Injection $1764.12 20% $352.82 
02/23/2021 Paclitaxel Injection $1423.90 20% $284.78 
02/23/2021 Paclitaxel Injection $541.10 20% $108.02 
01/28/2022 Denosumab Injection $1989.67 20% $372.10-Less than 
standard 20% 
Total:    $1,117.72 
 
The injections fall 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 the injections received on February 23, 2021, and January 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Needle electromyography provided on January 11, 2022 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for Needle electromyography. 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 it was determined these services were 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 Needle electromyography provided on January 11, 
2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 15, 2021 to September 11, 
2021 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 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 an office visit 
provided on July 15, 2021 to September 11, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 24, 2022. 
 
You asked the Plan to pay for an office visit. You say that you wanted to utilize this provider for a second 
opinion because you had surgery with this provider in the past and you were very pleased. The Plan denied 
your request. The Plan says you can get a second opinion with another network provider prior to surgery. Also, 
you do not have any out-of-network coverage. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on January 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for arthrocentesis provided on November 16, 
2021. 
 
You asked the Plan to waive the copayment for arthrocentesis. You say that you disagree that the benefit 
copayment is so high. You say that you believe the benefit should be different for a lower cost. 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 for Medicare-covered surgery provided in an outpatient hospital or ambulatory surgical center.  
 
 
 
 
 You have been asked to pay $242.62, which is less than the standard $275 copayment for arthrocentesis. 
Arthrocentesis falls 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 
arthrocentesis provided on November 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for catherization supplies provided from 
September 7, 2021, to December 1, 2021. 
 
You asked the Plan to waive the coinsurance for catherization supplies. You say that it is medically necessary 
that you receive the catherization supplies and that you thought they were covered. The Plan denied your 
request. The Plan says the coinsurance 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% 
coinsurance for Prosthetic devices and related supplies. 
 
 
 You have been asked to pay $177.84, which is 20% of the allowed amount for the catheterization supplies. The 
allowed amount is $889.20 (20% x $889.20 = $177.84). Catherization supplies fall within the Prosthetic 
devices 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 
catherization supplies provided from September 7, 2021, to December 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for chiropractic visits provided from April 7, 
2021 to December 16, 2021. 
 
You asked the Plan to waive the copayment for chiropractic visits. You say that you are requesting 
reimbursement of copays for each date of service. The Plan denied your request. The Plan says coinsurance 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 Medicare-covered chiropractic visit.  
 
  You have been asked to pay $1020 for chiropractic visits ($20/visit x 51 = $1020). Chiropractic visits falls 
within the Chiropractic visits benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. Your wallet benefit reimbursement is not for reimbursement of 
copayments for Medicare-covered services that have been billed to your 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 chiropractic visits provided from April 7, 2021 to December 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Occupational Therapy provided on August 12, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Occupational Therapy. You say that you would like to request reconsideration 
for payment. The Plan denied your request. The Plan says the health plan did not receive a response within the 
required timeframe; therefore, we cannot review 
the request. 
 
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 Occupational Therapy provided on August 12, 
2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from September 15, 2021, 
through September 27, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were necessary. The Plan 
denied your request. The Plan says that the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the review indicates that the record showed that at the time of inpatient admission the admitting 
physician reasonably expected that the patient's necessary hospital care (including earlier emergency 
department (ED) and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from September 15, 2021, through 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 31, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the provider is the enrollee's primary care physician, 
and you would like the claim paid. The Plan denied your request. The Plan says the rendering provider was an 
OON provider during the date of service and did not become the enrollee's primary care physician until 
February 1, 2022. 
 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 January 31, 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 introduction of needle(s) and/or catheter(s), dialysis 
circuit, with diagnostic angiography of the dialysis circuit, and a transluminal balloon angioplasty, central 
dialysis segment provided on January 7, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic 
angiography of the dialysis circuit, and a transluminal balloon angioplasty, central dialysis segment. You say 
that this provider was unable to obtain an authorization for these services. You also say that the patient has end 
state renal disease and is dependent on dialysis, hence the surgeon provided services based on the patient's 
necessity. The Plan denied your request. The Plan says this provider is not a network provider with the Plan, and they have also determined that these services are not urgent or emergent, nor were they 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 the introduction of needle(s) and/or catheter(s), 
dialysis circuit, with diagnostic angiography of the dialysis circuit, and a transluminal balloon angioplasty, 
central dialysis segment provided on January 7, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient rehabilitation stay provided 
from August 31, 2021, to September 14, 2021.  
 
You asked the Plan to waive the copayment for an inpatient rehabilitation stay. You say that you were told your 
surgery and rehabilitation would be combined in one claim. You also say you already made a payment of 
$1,374.34. 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 per day for days 1-4 for an inpatient rehabilitation stay. The contract says there is a $0 copayment 
for additional days after day 4. The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
total of $1,180, which is a $295 copayment per day for days 1-4 for an inpatient rehabilitation stay ($295 
copayment x 4 days = $1,180). An inpatient rehabilitation 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 rehabilitation stay provided from 
August 31, 2021, to September 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 14, 2021 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 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 an office visit provided on December 14, 2021 by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a nasal polyp biopsy/removal provided on 
December 9, 2021. 
 
You asked the Plan to waive the copayment for a nasal polyp biopsy/removal. You say that you believe that the 
extra $100 copayment was billed in error. 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 $100 
copayment for in-network outpatient surgery or other services at an outpatient hospital.  
 
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$100 copayment for a nasal polyp biopsy/removal. A nasal polyp biopsy/removal falls within the Outpatient 
Surgery and Other Medical 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 a nasal polyp 
biopsy/removal provided on December 9, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound provided on February 8, 2022. 
 
You asked the Plan to waive the copayment for ultrasound. You say that your copayment should be $15 for 
radiology services or $25 for diagnostic test procedures, and you paid $15 at the time of service. The Plan 
denied your request. The Plan says coinsurance 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 $115 
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 $108.64, which is less than the standard $115 copayment for an ultrasound. 
Ultrasound 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 ultrasound provided on February 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an annual wellness visit provided on 
November 15, 2021. 
 
You asked the Plan to waive the coinsurance for an annual wellness visit. You say that you went to see your 
primary care physician (PCP), and for the PCP you have a $0 copayment. 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 30% 
coinsurance for Medicare-covered preventive services for an annual wellness visit.  
 You have been asked to pay $42.05 in coinsurance, which is 30% of the allowed amount for an out-of-network, 
annual office visit ($140.18 allowed amount x 30% coinsurance = $42.05). 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 an annual wellness visit provided on November 15, 2021.