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

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on 
October 7, 2021. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that your doctor scheduled 
you for a colonoscopy. You say that you were awakened in the recovery room and informed they were unable 
to see anything. 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 $290 
in-network copayment for each Medicare-covered ambulatory surgical center visit.  
 
 
 
 
 You have been asked to pay a $290 in-network copayment for a diagnostic colonoscopy. The diagnostic 
colonoscopy 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 a diagnostic colonoscopy provided on October 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for MRI provided on November 13, 2021. 
 
You asked the Plan to waive the deductible for MRI. You say that the MRI should be a flat cost of $125 
because nowhere in the benefits does it say, "after deductible". The Plan denied your request. The Plan says 
there is a $500 in- and out-of-network deductible which applies to certain items and services. 
 
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 there is $500 in- and out-of-network deductible which applies to other 
outpatient diagnostic  radiological diagnostic services, not including x-ray.  
 
The item or service you asked the Plan to waive the deductible for falls within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that the $500 deductible applies to diagnostic tests. This cost sharing is a contractual 
obligation that had not been met at the time MRI was received on November 13, 2021. Therefore, we decided 
that the Plan does not have to waive the deductible for MRI provided on November 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) 
rendered by the out-of-network (OON) provider on March 8, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the subsequent nursing facility care, per day (99309) rendered by the out-of-network 
(OON) provider on March 8, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit (99284) 
provided on September 24, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. 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 $120 
copayment for Emergency care.  
 
 
  You have been asked to pay a $120 copayment for the ER visit. ER visits fall 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 emergency room (ER) visit 
(99284) provided on September 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 19, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that this claim needs to be processed as in-network. 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 January 19, 2022 by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested  
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. The Plan denied your request. The Plan says there is no documentation supporting that you have a 
medical condition or require a specialized medical procedure for which there is no in-network provider 
with the qualifications and expertise that are needed. Because in-network providers at in-network facilities are 
available to meet your needs; having care with an in-network provider at an in-network facility would not be 
detrimental to your health; and it is not medically necessary for you to see specialist/subspecialist rendering 
services outside of the Plans network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided the requested out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
December 13, 2021, to December 16, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you were not aware of any 
copayment at the time. 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 $250 per 
day for days 1-3 and $0 per day after day 3 for each inpatient admission.  
 
The file shows that you were in the hospital from December 13, 2021, to December 16, 2021, a total of three 
days. You have been asked to pay $250 per day for only the first two days of inpatient care, for a total of $500. The inpatient care falls within the Inpatient Hospital Coverage 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 inpatient hospital care provided from December 13, 2021, to December 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for IV) hydration and IV infusion in a doctors 
office on January 10, 2022. 
 
You asked the Plan to waive the copayment for intravenous IV hydration and IV infusion. You say that it looks 
like the plan does not pay for IV services in a doctors office. 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 $370 
copayment for Medicare Part B Prescription Drugs and Outpatient Surgery and Other Medical Services 
Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers.  
 
You have been asked to pay $292.41 which is a lesser amount then the copayment for IV hydration and IV 
infusion. IV hydration and IV infusion fall within the Medicare Part B Prescription Drugs and 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 intravenous IV) hydration 
and IV infusion in a doctors office on January 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
November 22, 2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that you changed your PCP to this 
provider in November 2021. 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 $25 
copayment for provider and professional services in a specialist's office.  
 
The file shows that the Plan verified a change of PCP request was not made before this visit. Therefore, you 
have been asked to pay a $25 copayment for the office visit. The office visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a specialist office visit provided on November 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an inflectra injection provided from 
October 1, 2021, to January 31, 2022.  
 
You asked the Plan to waive the coinsurance for an injection. You say that you were told that if the infusions 
were taking place in the hospital that you would not be responsible for any cost. 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 20% 
coinsurance for Part B drugs.  The record shows these claims were approved, and you have a cost sharing amount. You have been asked to 
pay $400.50, which is 20% coinsurance of the allowed amount for each injection received on October 1, 2021, 
October 29, 2021, and December 27, 2021 ($2002.49 allowed amount x 20% coinsurance = $400.50). You 
have also been asked to pay $394.53, which is 20% coinsurance of the allowed amount for an injection 
received on January 31, 2022 ($1,972.64 allowed amount x 20% coinsurance = $394.53). An injection falls 
within the Medicare Part B Prescription Drugs benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
coinsurance for an inflectra injection provided from October 1, 2021, to January 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on November 24, 
2021. 
 
You asked the Plan to waive the copayment for the office visit. 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 $20 
copayment for Physician/Practitioner services, including doctors office visits.  
 
 
  You have been asked to pay a $20 copayment for an office visit. The record indicates that additional services 
were provided during your wellness visit 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 office 
visit provided on November 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit and chronic care 
management services provided on January 20, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit and chronic care management services. You say 
that the assisted living facility is responsible to obtain prior authorization for all of their patients, which should 
also cover for the medical treatments provided by this provider. The Plan denied your request. The Plan says 
this provider is out-of-network with the Plan, and authorization was not obtained prior to the services being 
rendered. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a domiciliary or rest home visit and chronic care 
management services provided on January 20, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for glucose monitoring provided January 8, 
2021 to October 6, 2021. 
 
You asked the Plan to waive the copayment for glucose monitoring. You say that you should not be responsible 
for the copayment because the services should not be considered a test. 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 $65 
copayment for each covered diagnostic procedure or test at a network doctor's office.  
 
 
 
 
 
 You have been asked to pay a total of $210.42, which is less that the standard $65 copayment for glucose 
monitoring ($34.87 x 5 + $36.07 = $210.42). Glucose monitoring 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 
glucose monitoring provided January 8, 2021 to October 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
November 28, 2021, to December 14, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you were already charged for a 
stay from November 4, 2021, to November 10, 2021. You say you should not be charged since this stay is 
within 60 days of the previous stay. 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 $100 per 
day for days 1-5 and $0 per day for days 5-90 for each inpatient admission.  
 
The file shows that you were in the hospital from November 28, 2021, to December 14, 2021. Therefore, you have been asked to pay $100 per day for the first 5 days of inpatient care. The total for your stay is $500 ($100 
copayment x 5 days = $500). The inpatient care 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 inpatient hospital care provided from November 28, 2021, 
to December 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for physical therapy services (98941) provided 
from May 11, 2021, to December 29, 2021. 
 
You asked the Plan to waive the deductible for the physical therapy services. 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. Your 
contract with the Plan says that there is a $1500 deductible which applies to Chiropractic services.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category Chiropractic 
services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1500 
deductible which applies to Chiropractic services. This cost sharing is a contractual obligation that had not been 
met at the time the physical therapy services was received on May 11, 2021, to December 29, 2021. Therefore, 
we decided that the Plan does not have to waive the deductible for physical therapy services (98941) provided 
from May 11, 2021, to December 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the piflufolastat f-18 contrasting agent 
(A9595) provided March 16, 2022. 
 
You asked the Plan to waive the coinsurance for the piflufolastat f-18. 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 20% 
coinsurance for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a 20% coinsurance for the piflufolastat f-18 (allowed is $4,619.51 x 20% = 
$923.90). Piflufolastat f-18 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 coinsurance for the piflufolastat f-18 contrasting 
agent (A9595) provided March 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on February 9, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that you were not aware of the requirement of obtaining a 
prior authorization. The Plan denied your request. The Plan says the denial of payment for this service is 
correct, because this provider is out-of-network with the Plan and the ordering physician was also out-of-
network with the Plan. 
 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 drug testing provided on February 9, 2022 by an 
out-of-network (OON) provider.