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

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on May 04, 
2022. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you do not believe you should 
owe a copayment for the lab services. 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 laboratory tests. 
 
You have been asked to pay a $40 copayment for laboratory services. This item/service falls within the 
laboratory tests 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 May 04, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Medicare Part B prescription drugs and a 
specialist office visit provided on November 7, 2022. 
 
You asked the Plan to waive the cost share for Medicare Part B prescription drugs and a specialist office visit. 
You say that you disagree with 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 20% 
coinsurance for Medicare Part B prescription drugs and a $35 copayment for physician/practitioner 
services/specialist.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs and a $35 copayment 
for physician/practitioner services/specialist. The total allowed amount for the prescription drugs is $2,058. You are being asked to pay $411.60 ($2,058 x 20% = $411.60). You are being asked to pay $14.82 for the 
specialist office visit which is less than the required amount. The total amount you are being asked to pay fo all 
services rendered is $426.42 ($411.60 + $14.82 = $426.42). This item/service falls within the Medicare Part B 
prescription drugs and physician/practitioner services/specialist 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 cost share for Medicare Part B prescription drugs and a specialist office visit provided on 
November 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-share for supervised exercise therapy (SET) and a 
wrist-hand-finger orthosis provided on September 8, 2022. 
 
You asked the Plan to waive the cost-share for SET and the wrist-hand-finger orthosis. You say that you were 
not given a choice about receiving this service and item. 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 $10 
copayment for SET. Your contract with the Plan also clearly says that you must pay the 20% coinsurance for 
the durable medical equipment (DME).  
You have been asked to pay a $10 copayment for SET. This service falls into the supervised exercise therapy 
benefit category. You have also been asked to pay a $89.02 coinsurance for a wrist-hand-finger orthosis 
($445.08 allowed amount x 20% coinsurance = $89.02). This item falls into the durable medical equipment 
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 cost-share for supervised exercise therapy 
(SET) and a wrist-hand-finger orthosis provided on September 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic bone (DXA) scan provided on September 07, 
2022. 
 
You asked the Plan to pay for a diagnostic bone (DXA) scan. You say that this was medically necessary and 
should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a diagnostic bone 
(DXA) scan provided on September 07, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 20, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you were informed that the provider 
accepted your insurance. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on September 20, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network emergency room (ER) visit 
provided on September 30, 2022. 
 
You asked the Plan to waive the copayment for an in-network emergency room (ER) visit. You say that you 
were admitted to the hospital, therefore, you should not have to pay this 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 emergency care. 
 
You have been asked to pay a $50 copayment for an in-network emergency room (ER) visit. 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 
an in-network emergency room (ER) visit provided on September 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the in-network steroid injections provided 
on October 11, 2022. 
 
You asked the Plan to waive the copayment for steroid injections. You say that you say that you had these 
injections in a pain clinic not a hospital. 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 $395 
copayment for in-network surgery services provided in an outpatient hospital.  
 
This item/service falls within the in-network surgery services provided in an outpatient hospital benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan.  
 
You have been asked to pay $263.31 because the allowed amount for this service is less than the $395 
copayment 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 in-network steroid injections 
provided on October 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for principal care services provided on October 05, 2022. 
 
You asked the Plan to pay for principal care services. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for principal care services 
provided on October 05, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for infusion provided on October 21, 2022. 
 
You asked the Plan to reduce the copayment for infusion. You say that you were told the copayment was $300 
not $325. 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 $325 
copayment for outpatient hospital services. 
 
You have been asked to pay a $325 copayment for infusion. This item/service 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 reduce the copayment for infusion provided 
on October 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network acute inpatient stay provided 
from August 26, 2022, to August 30, 2022. 
 
You asked the Plan to waive the copayment for an in-network acute inpatient stay. You say that this is a large 
copayment, and you would like it reviewed. 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 $225 
copay applied per day for up to 5 days for inpatient hospital care. You had a 4 day stay, with a $225 copayment 
per day, resulting in a $900 total copayment ($225 x 4 days = $900). 
 
You have been asked to pay a $900 copay applied per day for up to 5 days for an in-network acute inpatient 
stay. This item/service 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 in-network acute inpatient 
stay provided from August 26, 2022, to August 30, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy provided 
on October 12, 2022. 
 
You asked the Plan to waive the copayment for the esophagogastroduodenoscopy. You say that you have not 
had to pay for these services in the past. 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 $350 
copayment for in-network Medicare-covered surgical procedures.  
 
According to Medicare, code 43239 is considered a surgical procedure and a separate procedure from a 
colonoscopy. You have been asked to pay a $350 copayment for an esophagogastroduodenoscopy. This 
item/service falls within the outpatient surgery 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 esophagogastroduodenoscopy provided on October 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on September 20, 2022. 
 
You asked the Plan to pay for nursing facility care. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for nursing facility care 
provided on September 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fungal infection polymerase chain reaction (PCR) panel 
provided on November 7, 2022. 
 
You asked the Plan to pay for the fungal infection PCR panel. You say that the testing was performed to hasten 
definitive diagnosis and efficiently treat the enrollee. The Plan denied your request. The Plan says PCR testing 
is not indicated as the following are appropriate means to verify fungal infection: direct microscopic 
examination with potassium hydroxide, fungal culture of desquamated subungual material, or fungal stain of a 
nail clippings fixed in formalin. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the fungal infection PCR panel. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the current standard of care for investigation of onychomycosis in a 
toenail is to perform a KOH and or fungal culture to the specimen. These lab tests are inexpensive, sensitive, 
and specific. It is unclear as to why this enrollee's right hallux toenail required PCR testing when other less 
expensive and efficacious lab tests are available. Therefore, it is my opinion that the requested PCR testing of 
this enrollee's right hallux toenail was not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the fungal infection PCR panel have not been met. Therefore, we decided that 
the Plan does not have to pay for the fungal infection polymerase chain reaction (PCR) panel provided on 
November 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided on August 09, 2022, to 
August 18, 2022. 
 
You asked the Plan to pay for the chiropractic services. You say that previous claims were paid with only a 
copayment due from the enrollee. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the chiropractic services 
provided on August 09, 2022, to August 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care office visit provided on 
November 1, 2022. 
 
You asked the Plan to waive the copayment for the urgent care office visit. You say that the provider only 
applied medicine and a bandage, and you should not have to pay for it. 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 $65 
copayment for urgently needed domestic services.  
 
You have been asked to pay a $65 copayment for an urgent care office 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 an urgent 
care office visit provided on November 1, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote physiologic monitoring provided on August 14, 
2022. 
 
You asked the Plan to pay for the remote physiologic monitoring. You say that the services were medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the remote physiologic 
monitoring provided on August 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (K0553) provided on 
September 20, 2022, to October 20, 2022. 
   
You asked the Plan to pay for the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as the enrollee does not meet the 
clinical requirements to be approved. 
 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (K0553) provided on 
September 20, 2022, to October 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 4, 2021. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the time 
limit for filing had expired. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the physician's services was not filed until September 22, 2022. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on January 4, 2021.