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

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided from April 26, 
2022, to May 4, 2022. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you were told that this stay 
would be covered through the plan, and that you could not afford a bill. The Plan denied your request. The Plan 
says the copayment applied was 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 
$150.00 per day, for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a $750 copayment for a 5-day inpatient stay ($150 x 5 = $750). An inpatient stay 
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 an inpatient stay provided from April 26, 2022, to May 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an out-of-network (OON) specialist office 
visit provided on June 10, 2022. 
 
You asked the Plan to waive the copayment for the OON specialist visit. You say that you were not informed 
the provider was out-of-network. 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 $65 
copayment for PCP and specialist visits with an out-of-network provider.  
 
The file shows that the Plan verified the provider is not a network provider. Therefore, you have been asked to 
pay a $65 copayment for the OON specialist visit. The OON specialist 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 out-of-network (OON) specialist office visit provided on June 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a laser procedure provided on April 13, 
2022. 
 
You asked the Plan to waive the copayment for a laser procedure. You say that you are disappointed with the 
Plan and their less than transparent nature of cost sharing. You would like this overturned due to this fact. 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 $100 
copayment for outpatient hospital visit.  
 
You are being charged $44.20 rather than the full copayment amount of $100 for a laser procedure. A laser 
procedure falls within the outpatient hospital visit 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 laser procedure provided on April 13, 2022.  
 Your complaint about the plan not being more transparent about the cost or cost sharing 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an acute inpatient hospital stay provided 
from April 8, 2022, to April 15, 2022. 
 
You asked the Plan to waive the copayment for an acute inpatient hospital stay. You say that you did not know 
that switching plans would cause an increase in inpatient hospital care. You say that you thought only the 
prescription amounts would change. 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 a $300 
copayment each time you are admitted to an acute care hospital.  
 
 
  You have been asked to pay a $300 copayment for an acute inpatient hospital stay. An acute inpatient hospital 
stay 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 an acute inpatient hospital stay provided from April 8, 2022, to April 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ear wax removal performed on December 
17, 2021. 
 
You asked the Plan to waive the copayment for the ear wax removal. You say that the provider went very fast 
and was not thorough with the procedure. 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 $50 
copayment for specialist visits.  
 
You have been asked to pay $39.64, which is less than the $50 copayment for the ear wax removal. The ear 
wax removal 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 ear wax removal performed on December 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3000). 
 
You asked the Plan to pre-approve foot orthotics. You say that you complain of painful right and left heel. You 
say the requested inserts are necessary. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3000).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee can receive further services at a lower 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for laboratory services provided from March 
24, 2022, to May 13, 2022. 
 
You asked the Plan to waive the copayments for the lab services. You say that you don't feel responsible for 
three copayments. 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 $10 per 
day, per provider, for lab services.  
 
The file shows that you saw two different providers for lab services on March 24, 2022. Therefore, you have 
been asked to pay copayments of $10 and $9.71 for the lab services. You have also been asked to pay a $3 
copayment for the lab services on May 13, 2022. The total for all services is $22.71. The lab services 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 copayments for laboratory services provided from March 24, 2022, to May 13, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy visits to be provided by OON provider. 
 
You asked the Plan to pre-approve physical therapy visits. The Plan denied your request. The Plan says this 
service is available with in-network providers. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy visits to be provided by an OON provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on April 
9, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that if someone at this 
facility had gotten in contact with you, you would not have had to go to the emergency room in the first place. 
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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for an emergency room visit. An emergency room 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 visit provided on April 9, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on April 13, 
2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you were informed that 
the provider was out-of-network and you had no way of knowing. 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 $350 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $350 copayment for the ambulance services. Please note that there is no 
difference in copayment amount for in-network or out-of-network services. The ambulance services fall within 
the Ambulance Services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance 
services provided on April 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an onabotulinumtoxina injection provided 
on January 28, 2022. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you were not made aware of the 
coinsurance before the injection. 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 20% 
coinsurance for Part B drugs. 
 
Drug Allowed Amount 20% Coinsurance 
Onabotulinumtoxina $1,135.80 $227.16 
Onabotulinumtoxina $126.20 $25.24 
Total:  $252.40 
 
 You have been asked to pay a total of $252.40, which is 20% of the allowed amount for two doses of the 
injection. The 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 onabotulinumtoxina injection provided on January 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a comprehensive hearing exam provided on 
February 25, 2022. 
 
You asked the Plan to waive the copayment for a comprehensive hearing exam. You say that you did not see 
the provider that day, and therefore should not have to pay this copayment. 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 $50 
copayment for Medicare-covered diagnostic hearing exam.  
 
You are being charged $42.51 rather than the full copayment amount of $50 for a comprehensive hearing 
exam. A comprehensive hearing exam falls within the Hearing 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 a comprehensive hearing exam provided on February 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Part B drugs on April 06, 2022. 
 
You asked the Plan to waive the coinsurance for Part B drugs. 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 20% 
coinsurance for all other drugs covered under Medicare Part B.  
 
 These drugs are covered under Part B of Original Medicare. Members of our plan receive coverage for these 
drugs through our plan. Covered drugs include drugs that usually arent self-administered by the patient and are 
injected or infused while you are getting physician, hospital outpatient, or ambulatory surgical center services. 
The enrollee is responsible for the $731.36 because the out-of-pocket maximum was not met and is responsible 
for 20% cost share for Part B medication. The Plan reprocessed claim at the in-network benefit of 20% cost 
share for the Part B injectable which would be $731.36 (allowable is $3656.80) and remove the cost share for 
administration. The Plan overturned the amount of $1,235.06 because it was processed at the out of network 
cost share in error. Therefore, results in the total cost sharing amount of $731.36. 
 
You have been asked to pay a 20% coinsurance for Part B drugs. Part B drugs 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 Part B drugs on 
April 06, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on May 21, 2022. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you had no idea the copayments were 
so high for this, and that you are on a fixed income, and this will cause a hardship. 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 $250 
copayment for other Medicare-covered diagnostic radiology services that are not ultrasounds.  
 
You are being charged $124.74 rather than the full copayment amount of $250 for a CT scan. A CT scan 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 computed tomography (CT) scan provided on May 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) rendered by 
the out-of-network (OON) provider from March 2, 2022, through April 6, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out-of-
network provider, without prior authorization. Additionally, the services provided were considered 
maintenance care which is not a covered benefit.  
 
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 services at issue in this appeal. 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 the chiropractic manipulative treatment (98941) rendered by the out-of-network 
(OON) provider from March 2, 2022, through April 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a full-size adjustable bed. 
 
You asked the Plan to pre-approve a full-size adjustable bed. You say that you need a bed, and it is medically 
necessary for your back. Your bed is now broken and its over 20 years old. You need a bed that fits two 
people. You have been sleeping in a chair for the past 30 days. You cannot lay flat because of your neck, and 
you cannot stand up straight because of your back. You are in severe pain. The Plan denied your request. The 
Plan says a full-size adjustable bed is not a covered benefit as it is considered a comfort/convenience item, not 
primary medical in nature. In addition, your primary care physician previously submitted an authorization 
request for a semi electric hospital bed which was delivered on September 16, 2022, to meet your needs, 
however you rejected the delivery. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a full-size adjustable bed.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a denosumab injection provided on 
November 24, 2021. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you cannot afford the coinsurance. 
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 20% 
coinsurance for Part B drugs.  
 
You have been asked to pay $254.28, which is 20% of the allowed amount for the injection ($1,271.40 allowed 
amount x 20% coinsurance = $254.28). The 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 a denosumab injection provided 
on November 24, 2021.