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

 
We decided that the Plan has to waive the cost share for outpatient hospital services provided on March 17, 
2021. 
 
You asked the Plan to waive the cost share for outpatient hospital services. You say that you did not have 
anything to pay for this cost share amount. The Plan denied your request. The Plan says that 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. Your 
contract with the Plan says that enrollees must pay $0 copayment for outpatient hospital services.  
 
The Plan says you must pay 20% coinsurance for outpatient hospital services. Based on the Plan contract, 
however, you cannot be asked to pay more than $0 copayment for outpatient hospital services. Therefore, we 
decided that the Plan has to waive the cost share for outpatient hospital services provided on March 17, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for MRI provided on December 11, 2021. 
 
You asked the Plan to waive the copayment for MRI. You say that your surgeon told you, you didn't need the 
MRI you could have just had the x-ray. The Plan denied your request. The Plan says copayment 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 per 
day for other Medicare-covered, diagnostic radiology services that are not ultrasounds.  
 
  You have been asked to pay $250 copayment for 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 
MRI provided on December 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a neurology specialist office visit provided 
on October 18, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you had met your 
maximum out-of-pocket (MOOP). 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 $35 
copayment for a specialist office visit.  
 
The record shows you had not met your MOOP at the time of the specialist office visit on October 18, 2021. 
You have been asked to pay a $35 copayment for a specialist office visit. A specialist office visit falls within 
the Physician/Practitioner Services, Including Doctors 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 neurology specialist office visit provided on October 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2752) for tooth #29. 
 
You asked the Plan to pre-approve the crown. You say that tooth #29 has a large filling and large decay. The 
Plan denied your request. The Plan says the enrollee's tooth has to have a lot of tooth missing from a cavity or 
have a lot of damage from being broken and it can no longer be fixed with a filling. The Plan also says that the 
x-rays show a crown is not needed to fix the enrollee's tooth. 
 
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 the crown 
when the services are medically necessary and reasonable.   
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 the crown. Our reviewer says that given 
the current condition of tooth #29, there is no necessity for a crown. Our physician reviewer found there are 
two involved surfaces with no clear cuspal involvement. Our reviewer found that under the Plan's criteria there 
would be no coverage provided for a crown as there were an insufficient number of surfaces and cusps 
involved. Note that due to the depth of the decay there is a strong possibility that root canal therapy may be 
required, at which time a post-treatment x-ray could be submitted with a request for a crown at that time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2752) for tooth #29.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and a laryngoscopy provided on November 29, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and a laryngoscopy. You say that this service is the gold standard 
and most accepted practice for examination of the larynx in those presenting with voice disorders, chronic 
laryngitis  and throat pain as did this patient. You also say that this is aligned with guidelines outlined by the 
Centers for Medicare and Medicaid Services (CMS), wherein all services for similar patients billed to CMS 
have been appropriately reimbursed. The Plan denied your request. The Plan says the services are not 
authorized because the rendering provider is a non-network provider who does not work with the Plan, and the 
member self-directed for care. The Plan also says that the member's primary care provider did not refer for 
services, and no medical necessity for an out-of-network provider such as an urgent or emergency situation, has been documented. The Plan also says that there is no network deficiency for these services and alternate 
network providers were found. 
 
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 and a laryngoscopy provided on 
November 29, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on November 
20, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that your surgeon said you must 
go in an ambulance or your health could be endangered. The Plan denied your request. The Plan says the 
copayment applied 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 $175 
copayment for Medicare-covered one-way ground ambulance services.  
 
You have been asked to pay $175 for the ambulance services. Ambulance services fall 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 the ambulance services 
provided on November 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided on February 24, 2022. 
 
You asked the Plan to waive the copayment for the x-ray. You say that the services should be covered as you 
disagree with the charges, and it took too long to receive your results. The Plan denied your request. The Plan 
says the cost-sharing applied correctly based on the services provided. 
 
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 for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $10 copayment for the x-ray. X-ray 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 February 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for infusion services provided from 
November 19, 2021, to November 24, 2021. 
 
You asked the Plan to waive the copayments for infusion services. You say that you were unable to receive the 
services at the hospital that you were released from because the cost share would have been greater. 
 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 $150 
copayment for in-network outpatient surgery and other medical 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 
$150 copayment for each infusion service from November 19, 2021, to November 24, 2021 ($150 copayment x 
6 infusions = $900). Infusion services fall 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 copayments for infusion services provided from November 19, 2021, to November 24, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for prophylaxis (D1110) provided by a participating provider on December 
23, 2021. 
 
You asked the Plan to pay for prophylaxis. You say that you were unaware that you maxed this benefit out. The 
Plan denied your request. The Plan says that D1110 has already been exhausted this year. 
 
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 Plan has failed to provide evidence to show that D1110 was previously 
applied. Therefore, we decided that the Plan has to pay for prophylaxis (D1110) provided by a participating 
provider on December 23, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2750) for tooth #'s 7, 8, and 9 and core 
buildups, including any pins when required (D2950) for tooth #'s 7, 8, and 9. 
 
You asked the Plan to pre-approve the crowns and core buildups. You say that porcelain crowns are needed to 
restore the teeth to full form and function for the best treatment for long term success. The Plan denied your 
request. The Plan says these services are not medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the crowns 
and core buildups when the services are medically necessary and reasonable.  
 
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 the crowns and core buildups. Our 
reviewer says that the documentation does not meet the criteria for coverage for core buildups (D2950) and 
crown restorations (D2750) for tooth #'s 7, 8, and 9. Our physician reviewer found the documentation indicates 
that tooth #'s 7, 8, and 9 do not exhibit significant coronal breakdown due to caries or fracture to warrant these 
services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crowns and core buildups have not been met. Therefore, we decided that the 
Plan does not have to pre-approve crowns (D2750) for tooth #'s 7, 8, and 9 and core buildups, including any 
pins when required (D2950) for tooth #'s 7, 8, and 9.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
November 8, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you feel like you 
shouldn't have to pay a copayment for one visit. The Plan denied your request. The Plan says the copayment 
applied 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 $25 
copayment for a specialist office visit.  
 
You have been asked to pay $25 for the specialist office visit. Specialist office visits s 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 the specialist office visit provided on November 8, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breast ultrasound provided on December 
27, 2021. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you did not know that ultrasounds 
had a copayment. You also say that you feel a $100 is a high amount to pay. 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 an ultrasound.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
the allowed amount of $93.87, which is less than the $100 copayment for an ultrasound. An 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 a breast ultrasound provided on December 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for an intravenous infusion (96365, 96366) 
and privigen injection (J1459) provided on December 2, 2021. 
 
You asked the Plan to waive the cost-sharing for the intravenous infusion and privigen injection. You say that 
the services should be covered as you disagree with the charges. The Plan denied your request. The Plan says 
the cost-sharing applied correctly based on the services provided. 
 
  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 Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers and a 20% coinsurance for Medicare Part B Prescription Drugs, and the 
administration of them.  
 
You have been asked to pay a $282.09 copayment for the intravenous infusion, which is less than the standard 
$350, and a 20% coinsurance for a privigen injection (allowed is $2,668.8 x 20% = $533.76). 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-sharing for an intravenous infusion (96365, 96366) and privigen injection 
(J1459) provided on December 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on April 13, 2021. 
 
You asked the Plan to waive the copayment for office visit. You say that you believe the discussion of chronic 
conditions should be covered under the annual physical exam, which has not copayment. The Plan denied your 
request. The Plan says copayment 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 in-network, Medicare covered service received from primary care provider.  
 
  You have been asked to pay $20 copayment for office visit. Office visits fall within the Physician/Practitioner 
services, including doctor's office visits benefit category. The medical records show you received services 
outside a routine physical. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visit provided on 
April 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Psychiatric Diagnostic Evaluation Services provided on 
December 13, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Psychiatric Diagnostic Evaluation Services. You say that you are requesting 
reconsideration stating that this is medically necessary. 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 Psychiatric Diagnostic Evaluation Services 
provided on December 13, 2021 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 the inpatient hospital stay provided from 
December 29, 2021, to January 1, 2022 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you've been paying all 
kinds of medical bills and would like this bill reduced. The Plan denied your request. The Plan says the 
copayment applied 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 $350 per 
day for days 1-5 and $0 after day 5 each time you are admitted to an acute care hospital.  
 
You have been asked to pay a total of $1,050 ($350 copayment x 3 days = $1,050). Inpatient hospital stays 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 copayment for 
the inpatient hospital stay provided from December 29, 2021, to January 1, 2022.