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

 
We decided that the Plan does not have to waive the copayment for office visit on April 21, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged 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 a $25 
copayment for each Medicare-covered specialist visit. Covered services include consultation, diagnosis, and 
treatment by a specialist. 
 
You have been asked to pay a $25 copayment for office visit. Office visits fall within the Physician/practitioner 
service, 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 
office visit on April 21, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a power wheelchair with additional features. 
 
You asked the Plan to pre-approve the requested power wheelchair. The Plan denied your request. The Plan 
says that this type of wheelchair is not medically necessary. 
 
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 did not submit medical records with the case file to support its denial. 
Upon a request for records, the Plan submitted additional information containing wheelchair price quotes, with 
no records. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided 
that the Plan has to pre-approve a power wheelchair with additional features.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a future transthoracic echocardiogram 
(TTE) with doppler. 
 
You asked the Plan to waive the copayment for the TTE with doppler. You say that you need the test, but you 
won't be able to afford the copayment. The Plan denied your request. The Plan says the cost sharing cannot be 
waived. 
 
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 there is a $100 
copayment per day for ultrasounds.  
 
Per the EOC, there is a $100 copayment per day for ultrasounds. The TTE with doppler is an ultrasound 
procedure and falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit 
category. 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 future transthoracic 
echocardiogram (TTE) with doppler.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gym membership purchased July 17, 2021, for the year 
2021. 
 
You asked the Plan to pay for the gym membership. You say that your policy ran on a fiscal year and not on a 
calendar year. The Plan denied your request. The Plan says your reimbursement request was not filed on time. 
Additionally, the Plan indicates that the portion of the request for gym benefits received in 2022, has been 
processed according to your 2022 Wellness Allowance. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only when a reimbursement request is submitted by March 31st of the following year. 
 
The Plans rules for coverage of gym benefits have not been met because the request for reimbursement for 
gym benefits used in 2021, was submitted after March 31st of 2022. Therefore, we decided that the Plan does 
not have to pay for the gym membership purchased July 17, 2021, for the year 2021.  
 Your complaint about potentially receiving misinformation from a plan representative 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the out-of-network (OON) home health 
services provided on March 12, 2022, to April 07, 2022. 
 
You asked the Plan to waive the coinsurance for the out-of-network (OON) home health services. You say that 
you would not have chosen an out-of-network provider if you had known. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for out-of-network (OON) home health agency care. 
 
You have been asked to pay 20% coinsurance for the out-of-network (OON) home health services. This 
item/service falls within the out-of-network (OON) home health agency 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. The file shows that the Plan verified 
the home health agency is not a network provider. The 20% coinsurance applied to the allowed amount for each visit is a total of $350.58. Therefore, we decided that the Plan does not have to waive the coinsurance for 
the out-of-network (OON) home health services provided on March 12, 2022, to April 07, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
September 14, 2021. 
 
You asked the Plan to waive the copayment for ambulance transportation. You say that you should not be 
responsible to pay this. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for ambulance services. 
 
You have been asked to pay a $250 copayment for ambulance transportation. This item/service 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 
transportation provided on September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on May 09, 2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that I should not have this 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $35 copayment for a specialist visit. This item/service 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 specialist visit provided on May 09, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ophthalmologist visit provided on June 
2, 2022. 
 
You asked the Plan to waive the copayment for an ophthalmologist visit. You say that you should not have this 
large of a copayment. The Plan denied your request. The Plan says the copayment applied were 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 a $20 
copayment for vision care.  
 
You have been asked to pay a $60 copayment for an ophthalmologist visit ($20 for the office visit and $40 for a 
non-covered test = $60). An ophthalmologist visit falls within the vision 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 ophthalmologist visit provided on June 2, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on November 14, 
2022, to November 16, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that the enrollee wants to 
appeal the amount being charged. The Plan denied your request. The Plan says the cost sharing the enrollee is 
being charged 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $220 copayment per day for days 17 of a hospital stay for Greater Sacramento Area and Sonoma 
County Enhanced plan members. The day before you are discharged is your last inpatient day. There is no limit 
to the number of medically necessary hospital days or services that are generally and customarily provided by 
acute care general hospitals. The visit was 2 days. $220 x 2 = $440. Therefore, results in the total cost sharing 
among of $440.  
 
 The enrollee has been asked to pay a $220 copayment each day for inpatient hospital stay. Inpatient hospital 
stay falls within the Inpatient hospital care benefit category. This means that the enrollee has been asked to pay 
the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for inpatient hospital stay on November 14, 2022, to November 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for laboratory services provided on March 31, 
2022. 
 
You asked the Plan to waive the deductible for laboratory services. You say that you should not be responsible 
to pay this. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 
$110.29 deductible for medical benefits chart. 
 
You have been asked to pay a $110.29 deductible for laboratory services. This item/service falls within the 
medical benefits chart 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 deductible for laboratory 
services provided on March 31, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on March 18, 
2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that want this copayment waived. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for Physician/Practitioner services- including doctors office visits. 
 
You have been asked to pay a $25 copayment for a specialist visit. This item/service 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 specialist visit provided on March 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99205) provided on April 25, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that there is an approved authorization for code 99203. 
You say you would like for the medical records to be reviewed and for the claim to be reprocessed and paid. 
The Plan denied your request. The Plan says at the time of service, the rendering provider was out-of-network. 
The Plan determined that the provider did not become an active network provider until after April 25, 2022. 
Furthermore, the submitted claim clearly shows procedure code 99205 was rendered to the enrollee. 
 
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 (99205) provided on April 25, 2022, 
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 endoscopy on September 20, 2021. 
 
You asked the Plan to waive the copayment for endoscopy. You say that you shouldn't be responsible for the 
cost share applied to this claim because this is not surgery so you shouldn't have a copayment. The Plan denied 
your request. The Plan says the cost sharing you are being charged 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 a $450 
copayment for each outpatient hospital observation visit. Observation services are hospital outpatient services 
given to determine if you need to be admitted as an inpatient or can be discharged.  
 
You have been asked to pay a $450 copayment for endoscopy. Endoscopy falls within the Outpatient hospital 
observation 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 endoscopy on September 
20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the podiatry services provided on March 
22, 2022. 
 
You asked the Plan to waive the copayment for the podiatry services. You say that you are requesting the 
services to be paid. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for podiatry services. 
 
You have been asked to pay a $25 copayment for the podiatry services. This item/service falls within the 
podiatry 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 podiatry services 
provided on March 22, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound on May 18, 2022. 
 
You asked the Plan to waive the copayment for ultrasound. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged 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 a $150 
copayment for Medicare-covered radiological diagnostic services, not including X-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic). Covered services 
include but are not limited to other outpatient diagnostic tests -Radiological diagnostic services, not including 
x-rays. The provider billed in the amount of $947 and the allowed amount is $102.53. This is less than the 
copayment amount. Therefore, results in the total cost sharing amount of $102.53. 
 
 
 You have been asked to pay a $102.53 copayment, which is less than the copayment for ultrasound. 
Ultrasounds 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 ultrasound on May 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient admission. 
 
You asked the Plan to pre-approve inpatient admission. You say that you want the Plan to approve the services. 
The Plan denied your request. The Plan says there are no medical records to support that the services are 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of inpatient admission. have been met. 
Specifically, the documentation does not include medical records. Therefore, we decided that the Plan does not 
have to pre-approve inpatient admission.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided to the 
enrollee on March 27, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you did not know the 
ambulance company was out-of-network. The Plan denied your request. The Plan says the enrollee was 
charged this cost sharing 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $375 copayment for each one-way ambulance service.  
 
The enrollee has been asked to pay a $375 copayment for the ambulance services. The ambulance services fall 
within the Ambulance Services benefit category. This means that the enrollee has been asked to pay the correct 
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to 
pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
ambulance services provided to the enrollee on March 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on April 20, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you should not have to pay another 
copayment for this. The Plan denied your request. The Plan says you were charged this cost sharing 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 $130 
copayment for outpatient diagnostic tests and therapeutic tests.  
 
You have been asked to pay a $111.42 copayment, rather than the full copayment amount of $130 for an 
ultrasound. An ultrasound falls within the Outpatient Diagnostic Tests and Therapeutic Tests benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an ultrasound provided on April 20, 2022.