Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from 
September 3, 2021, to September 9, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were informed 
that all COVID-19 related treatment was fully covered. 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 $300 per 
day for days 1-5 and $0 per day for additional days for each inpatient stay.  
 
The file shows that you were in the hospital from September 3, 2021, to September 9, 2021. You have been 
asked to pay $300 per day for the first 5 days of inpatient hospital services. The total for your stay is $1,500 ($300 copayment x 5 days = $1,500). Please note that COVID-19 cost share waivers ended on May 31, 2021. 
The inpatient hospital services fall within the Inpatient Hospital Care benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for inpatient hospital services provided from September 3, 2021, to 
September 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray exam of the hand (73130) rendered by the out-of-
network (OON) provider on October 12, 2021. 
 
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 x-ray exam of the hand (73130) rendered by the out-of-network (OON) provider 
on October 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on October 13, 
2021. 
 
You asked the Plan to waive the copayment for an office visit. You say that this was your annual wellness 
exam and you should not owe a copayment. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct 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 $10 
copayment for primary care provider visits. 
 
The medical records show that you received services beyond an annual wellness visit on October 13, 2021. 
Therefore, you are responsible to pay the $10 copayment.   
 You have been asked to pay a $10 copayment for an office visit. An 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 an office visit provided on October 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cataract surgery provided on August 10, 
2021. 
 
You asked the Plan to waive the copayment for cataract surgery. You say that you were told by multiple people 
that your insurance covered this surgery, which you understood to mean there was no copayment. You also say 
you were not requested to pay a copayment at the surgery center. 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 $240 
copayment for in-network outpatient surgery at an ambulatory surgical center.  
 
 You have been asked to pay a $240 copayment for cataract surgery. Cataract surgery 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 cataract surgery provided on August 10, 2021.  
 
Your complaint about not being given the correct information is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on November 1, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that this was the first claim 
for dental service code D0140 and you do not understand how it exceeds the limitation when this was the first 
time. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit 
plan. 
 
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. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on November 4, 2021 and your problem focused limited oral 
evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for 
the problem focused limited oral evaluation (D0140) provided on November 1, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the copayment for a computed tomography (CT) scan of the face 
provided on October 21, 2021. 
 
You asked the Plan to waive the copayment for a CT scan. You say that this was an office visit. You also say 
you paid your $25 copayment that was due for a specialist visit. The Plan denied your request. The Plan says 
that you have been charged the correct cost sharing amount. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided medical records to show whether the CT scan was 
performed. Therefore, we decided that the Plan has to waive the copayment for a computed tomography (CT) 
scan of the face provided on October 21, 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 reimburse you for eyeglasses provided on July 15, 2021. 
 
You asked the Plan to reimburse you for the eyeglasses. You say that you were not aware that there would be 
no reimbursement as there was in the past. You say when you called for a reimbursement form you were not 
told that you had to go to an in-network provider. The Plan denied your request. The Plan says you must use 
the Plan's vision vendor to receive the benefit. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services when you use the Plans vision insight network provider. 
 We looked at the file and the Plan's rules. The file shows that the eyeglasses were not provided by the Plans 
vision network provider. Based on this information, we decided that the Plan's rules for coverage of the 
eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you for 
eyeglasses provided on July 15, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic test provided on 
September 20, 2021. 
 
You asked the Plan to waive the copayment for the outpatient diagnostic test. You say that the provider never 
told you that there would be a copayment for this service. The Plan denied your request. The Plan says the 
proper copayment was applied for this service. 
 
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 Specialty Physician for other Medicare-covered outpatient diagnostic tests.  
 
  You have been asked to pay a $50 copayment for the outpatient diagnostic test. The outpatient diagnostic test 
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 an outpatient diagnostic test provided on September 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from 
November 23, 2020, to November 28, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you do not know 
why the bills were not paid. 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 $225 per 
day for days 1-7 and $0 per day for days 8-90 for each inpatient stay.  
 
The file shows that you were in the hospital from November 23, 2020, to November 28, 2020. You have been 
asked to pay $225 per day for the first 5 days of inpatient hospital services. The total for your stay is $1,125 ($225 copayment x 5 days = $1,125). The inpatient hospital services fall within the Inpatient Hospital Care 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital services 
provided from November 23, 2020, to November 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services for special ophthalmological services 
and procedures provided on March 11, 2021. 
 
You asked the Plan to pay for the physician's services for special ophthalmological services and procedures. 
The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility. 
 
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 physician's services for special ophthalmological 
services and procedures provided on March 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breast biopsy provided on October 11, 
2021. 
 
You asked the Plan to waive the copayment for a breast biopsy. You say that you disagree with how high the 
charges are. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct 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 $345 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
 You received a breast biopsy at an outpatient hospital facility on October 11, 2021. A breast biopsy is 
considered an outpatient surgical procedure. Therefore, you are responsible to pay the $345 copayment.  
 
You have been asked to pay a $345 copayment for a breast biopsy. A breast biopsy 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 breast biopsy provided on 
October 11, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on October 29, 
2021 by an out-of-network (OON) provider. 
 
  You asked the Plan to pay for the domiciliary or rest home visit. You say that it was medically necessary for 
the enrollee to receive the treatment that was rendered. You also say that you did not know that the facility 
failed to get pre-authorization for this enrollee. The Plan denied your request. The Plan says the services were 
not referred or rendered by a network provider or rendered in an in-network facility. The Plan also says 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 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 domiciliary or rest home visit provided on 
October 29, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy (PT) services provided from September 
1, 2021, to September 30, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the PT services. You say that authorization was obtained for the services. The 
Plan denied your request. The Plan says the claim was processed correctly. 
 
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 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 physical therapy (PT) services provided from September 1, 
2021, to September 30, 2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy performed on 
November 12, 2021. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that you were informed by Plan 
representatives that the entire cost would be covered. 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 $350 
copayment for each ambulatory surgical center visit.  
 
 
 You have been asked to pay a $350 copayment for the colonoscopy. Please note that the polyp removal makes 
the procedure surgical. While the procedure is covered, the copayment for surgery applies. The colonoscopy 
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 a diagnostic 
colonoscopy performed on November 12, 2021.  
 
Your complaint about Plan representatives giving misinformation is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
October 22, 2021. 
 
You asked the Plan to waive the copayment for the PT services. You say that you feel that the service was 
denied and the claim should be reprocessed. 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 $20 
copayment for each physical therapy visit.  
 You have been asked to pay a $20 copayment for the PT services. The PT services fall within the Outpatient 
Rehabilitation 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 physical 
therapy (PT) services provided on October 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgery you had on 
December 7, 2021. 
 
You asked the Plan to waive the copayment for the outpatient surgery. You say that you believe the facility 
where you received the surgery is an ambulatory surgery center, so no copayment should apply. The Plan 
denied your request. The Plan says this copayment was charged correctly.  The Plan says that although the 
location where you had the surgery has a different address than the main hospital, it is on the hospital's campus 
and the facility is considered an outpatient hospital facility. 
 
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 outpatient surgery at an outpatient hospital facility.  
 
 
 
 You have been asked to pay a $150 copayment for the outpatient surgery. The facility where you received these 
services is considered an outpatient hospital facility.  We confirmed on the Plan's online directory that this 
facility is not considered an ambulatory surgery center. 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 outpatient surgery you had on December 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for collagenase injections (J0775) provided on 
September 7, 2021. 
 
You asked the Plan to waive the coinsurance for the collagenase injections. You say that the services should be 
covered in full as you should have been informed how much the 20% would be beforehand. The Plan denied 
your request. The Plan says the coinsurance 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 Medicare Part B prescription drugs and the administration of them. 
 
You have been asked to pay a 20% coinsurance for the collagenase injections (total allowed is $10,086.13 x 
20% = $2,017.23). Collagenase 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 collagenase injections (J0775) provided on September 7, 
2021.