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

 
We decided that the Plan does not have to waive the coinsurance for a synvisc injection (J7325) provided on 
February 11, 2022. 
 
You asked the Plan to waive the coinsurance for the synvisc injection. You say that the services should be 
covered as you disagree with the charges and were not made aware of them. 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.  
 
 
  You have been asked to pay a 20% coinsurance for the synvisc injection (allowed is $492.96 x 20% = $98.59).  
Synvisc 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 a synvisc injection (J7325) provided on February 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 22, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on November 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 29, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services provided on January 29, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for Part B drugs provided on September 23, 2021, and 
October 21, 2021. 
 
You asked the Plan to waive the coinsurance for Part B drugs. You say that the drug charges should be 
included into the copayment for outpatient surgery. The Plan denied your request. The Plan says that you have 
been charged the correct cost sharing amount. 
 
The Plan says you must pay a total of $42.19, which is 20% coinsurance for Part B drugs. According to 
Medicare, all the Part B drugs codes that applied a cost sharing amount on these claims are considered 
packaged codes. Therefore, the codes are not separately payable. We decided that the Plan has to waive the 
coinsurance for Part B drugs provided on September 23, 2021, and 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for pulmonary rehabilitation services provided 
from January 5, 2022, to January 27, 2022. 
 
You asked the Plan to waive the copayment for the pulmonary rehabilitation 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for Pulmonary rehabilitation services.  
 
 
  You have been asked to pay a $210 copayment for 7 pulmonary rehabilitation visits ($30 x 7 = $210). 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 pulmonary rehabilitation services provided from January 5, 
2022, to January 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy services provided on 
February 14, 2022 
 
You asked the Plan to waive the copayment for physical therapy services. You say that you stopped in the 
middle of stretches during your physical therapy visit on February 14, 2022. You also say that neither you nor 
the insurance company should have to pay for that visit. 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 physical therapy visit.  
 
The medical record shows you received physical therapy services on February 14, 2022. You have been asked 
to pay a $35 copayment for physical therapy services. Physical therapy 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 services provided on February 14, 2022
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the 
upper spinal canal provided on January 18, 2022. 
 
You asked the Plan to waive the copayment for an MRI. You say that you called the insurance company prior 
to having the MRI and were told the facility was in-network. 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 diagnostic radiology services, including MRIs.  
 
According to the EOC, the cost sharing amount is the same whether services were received from an in-network 
or out-of-network provider. You have been asked to pay a $150 copayment for an MRI. An 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 a magnetic resonance imaging (MRI) of the upper spinal canal 
provided on January 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for a specialist office visit and 
methylprednisolone injection provided on January 12, 2022. 
 
You asked the Plan to waive the copayment and coinsurance for the office visit and injection. You say that you 
were informed that the provider was in-network and should be fully covered. The Plan denied your request. 
The Plan says the correct copayment and coinsurance was applied. 
 
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 each specialist visit. 
 
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for Part B drugs. 
 You have been asked to pay a $35 copayment for the office visit. The office visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. You have also been asked to 
pay $2.36 for the injection, which is 20% of the allowed amount ($11.82 allowed amount x 20% coinsurance = 
$2.36). The injection falls within the Medicare Part B Prescription Drugs benefit category. The total for the 
visit is $37.36. 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 and coinsurance for a specialist office visit and 
methylprednisolone injection provided on January 12, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cardiac rehabilitation services provided 
from December 14, 2021, to December 29, 2021.  
 
You asked the Plan to waive the copayment for cardiac rehabilitation services. You say that you did not have a 
copayment when you had cardiac rehabilitation before. 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 $10 
copayment for outpatient rehabilitation services.  
 
You have been asked to pay a $10 copayment for each cardiac rehabilitation visit from December 14, 2021, to 
December 27, 2021 ($10 copayment x 6 visits = $60). You have also been asked to pay $5, which is less than 
the $10 copayment for a cardiac rehabilitation visit on December 29, 2021. You have been asked to pay a total 
of $65 ($60 copayment + $5 copayment = $65). Cardiac rehabilitation 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 cardiac 
rehabilitation services provided from December 14, 2021, to December 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services provided on 
December 14, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management services provided by an OON provider. You say 
that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says 
the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-
of-network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the evaluation and management services provided 
on December 14, 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 transport provided on August 
10, 2021. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that this is part of a previously 
approved claim and somehow was missed.  You say that this claim came in after you had reached your out-of-
pocket maximum. 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 $250 
copayment for each one-way Medicare-covered ground trip.  
 
 
 You have been asked to pay $247.21 which is less than the standard $250 copayment. Ambulance transport 
falls 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 
ambulance transport provided on August 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic activities (97530) provided on February 23, 
2021. 
 
You asked the Plan to pay for code 97530. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
Medicare rules say that the services of an OTA shall not be billed as services incident to a physician/non-
physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of occupational therapy have not been met. Specifically, the billing provider is a nurse practitioner, 
and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's professional 
services. Therefore, we decided that the Plan does not have to pay for the therapeutic activities (97530) 
provided on February 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for X-rays of the hip provided on January 10, 
2022. 
 
You asked the Plan to waive the copayment for the X-rays. You say that you already paid the office visit 
copayment. You say that you do not know what the extra charge is for. 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 each standard X-ray service.  
 
You have been asked to pay a $35 copayment for the X-rays. The X-rays 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 X-rays of the hip provided on January 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Intermittent urinary catheter provided on March 21, 2022 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for Intermittent urinary catheter. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the provider is out-of-network and 
authorization is required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for Intermittent urinary catheter provided on March 
21, 2022 by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
October 15, 2021. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you went to the ER after a fall and the 
hospital ordered a cat scan and x-rays. You also say that they wanted to do more tests, but you left, and you 
should not have to pay the copayment for the ER doing nothing. 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 $50 
copayment for an in-network emergency room visit.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$50 copayment for an ER visit. An ER visit 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 emergency room (ER) visit provided on October 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 20, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the services provided were medically necessary. The 
Plan denied your request. The Plan says the service was performed by an OON provider were not authorized 
and were not referred by a participating provider. 
 
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 September 20, 2021 by 
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan (70450) 
provided on January 27, 2022. 
 
You asked the Plan to waive the copayment for the CT scan. 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 $75 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $75 copayment for a CT scan. CT scans 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 a computed tomography (CT) scan (70450) provided on January 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
September 1, 2021, to September 17, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. 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 $225 
copayment per day for days 1-7 of Inpatient hospital care.  
 
 
  You have been asked to pay a $1,575 copayment for 7 days of inpatient hospital care $225 x 7 = $1,575). 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 September 1, 2021, to 
September 17, 2021.