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

 
We decided that the Plan does not have to waive the cost share for obinutuzumab injections and specialist 
physician services provided from October 11, 2021, to October 25, 2021. 
 
You asked the Plan to waive the cost share for injections and specialist physician services. You say that you do 
not understand why cancer medication would not be fully covered. The Plan denied your request. The Plan says 
you have been charged the correct sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for in-network Part B drugs. The Plan contract also says that enrollees must pay a $35 copayment for in-network specialist physician services. 
 
You have been asked to pay a total of $2,972.48, which is 20% coinsurance of the allowed amount for 
injections. An injection falls within the Medicare Part B Prescription Drugs benefit category.  
 
Date of Service Code Allowed Amount 20% Coinsurance 
October 11, 2021 J9301 $4,458.72 $891.74 
October 11, 2021 J9301 $495.41 $99.08 
October 18, 2021 J9301 $4,954.14 $990.83 
October 25, 2021 J9301 $4,954.14 $990.83 
Total   $2,972.48 
 
You have also been asked to pay a total of $140, which is a $35 copayment for each specialist physician service 
on October 11, 2021, October 12, 2021, October 18, 2021, and October 25, 2021 ($35 copayment x 4 services 
= $140). You have been asked to pay a total of $3,112.48 ($2,972.48 coinsurance + $140 copayments = 
$3,112.48). A specialist physician 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 cost share for obinutuzumab injections 
and specialist physician services provided from October 11, 2021, to October 25, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Home Health Services provided on June 17, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Home Health Services. 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 it was determined 
these services were not urgent or emergent. 
 
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 Home Health Services provided on June 17, 2021 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the lab services provided on December 21, 
2021.  
 
You asked the Plan to waive the deductible for the lab services. You say that you read that lab services were 
$10 per day, per deductible and that a copay may apply. The Plan denied your request. The Plan says the 
deductible applied 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 in-network Medicare-covered lab services and that your deductible may apply. Your 
$300 annual deductible had not been met at the time of your lab service which is why the $10 copayment does 
not apply.  
 
 
  You have been asked to pay a total of $73.88 for lab services. 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 deductible for laboratory services provided on December 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Genetic Testing provided on November 29, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Genetic Testing. You say that the test performed immediately to help better 
determine course of treatment. The Plan denied your request. The Plan says the denial is based on there not 
being enough medical documentation supplied in what was submitted. 
 
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 Genetic Testing provided on November 29, 2021 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay the copayment for an inpatient hospital stay provided from April 
22, 2021, to April 30, 2021. 
 
You asked the Plan to pay the copayment for the inpatient hospital stay. You say that you would like the Plan 
to cover the remaining cost based on complications from COVID-19. The Plan denied your request. The Plan 
says as of April 1, 2021, there are no cost share waivers in effect for COVID-19 treatments. Therefore, the 
proper copayment was applied for the service that was rendered. 
  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 $265 
copayment for each day for days 1 to 7 for Medicare-covered hospital care and a $0 copayment for additional 
Medicare-covered days. From April 22, 2021, to April 30, 2021, there was a total of 9 days for the inpatient 
hospital stay. With only 7 days being charged a copayment the total copayment amount was $1,855 ($265 
copayment amount per day x 7 days). 
 
You have been asked to pay a $1,855 copayment for the inpatient hospital stay. The 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 pay the copayment for an 
inpatient hospital stay provided from April 22, 2021, to April 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit on November 23, 2021. 
 
You asked the Plan to waive the copayment for an office visit. You say that the provider wasn't a doctor, why 
am I being charged for copayment? The Plan denied your request. The Plan says a copayment is the fixed 
amount you pay each time you receive certain medical services and 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 $30 
copayment for an office visit.  
 
You have been asked to pay a $30 copayment for an office visit. An office visit 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 an office visit on November 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an electrocardiogram (EKG) and a 
cardiology specialist office visit provided on October 12, 2021. 
 
You asked the Plan to waive the copayments for an EKG and a specialist office visit. You say that the bill you 
received for the EKG is a mistake and the insurance company must pay for it. 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 non-radiological diagnostic services, including EKGs. The Plan contract also says that enrollees must pay a $40 copayment for a specialist office visit.   
 
The record shows this claim was approved, and you have a cost sharing amount for both services. You have 
been asked to pay the allowed amount of $14.39, which is less than the $20 copayment for an EKG. An EKG 
falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. You have 
also been asked to pay a $40 copayment for a specialist office visit. You have been asked to pay a total of 
$54.39 ($14.39 copayment + $40 copayment = $54.39). A specialist office visit falls within 
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 copayments for an electrocardiogram (EKG) and a cardiology specialist office visit provided on 
October 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Genetic Testing provided on July 7, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Genetic Testing. You say that you would like to appeal the denial of the claim. 
The Plan denied your request. The Plan says it was determined these services were not medically necessary. 
 
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 Genetic Testing provided on July 7, 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 services provided on December 
8, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that hospital staff could not get 
you in your car so they called for an ambulance and did not indicate there would be a charge. The Plan denied 
your request. The Plan says the copayment applied 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 each one-way Medicare-covered ground trip.  
 
You have been asked to pay $222.65, which is less than the standard $250 copayment for ambulance services. 
The ambulance 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 services provided on December 8, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a transthoracic echocardiogram (TTE) with 
doppler provided on November 10, 2021. 
 
You asked the Plan to waive the deductible for the TTE with doppler. You say that you should only be 
responsible for the copayment. The Plan denied your request. The Plan says the correct amount was applied to 
your deductible. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $1,000 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for is a radiological ultrasound, and falls within 
the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is $1,000 deductible which applies to certain 
items and services. This cost sharing is a contractual obligation that had not been met at the time the TTE with 
doppler was received on November 10, 2021. Therefore, we decided that the Plan does not have to waive the 
deductible for a transthoracic echocardiogram (TTE) with doppler provided on November 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 2, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that this claim was denied incorrectly. You also say that 
this provider is a participating contracted provider and no referral is needed for Medicare plans. The Plan 
denied your request. The Plan says this provider is not a network provider with the Plan, and they have also 
determined that these services are not urgent or emergent, nor were they approved in advance. The Plan also 
says that this referral was not authorized by the primary care physician. 
 
 
 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 December 2, 2021, by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from June 
14, 2021, to June 18, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that this was a hospital at 
home and was advised the Plan would pay everything. 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 $215 
copayment per day for days 1-7 for inpatient hospital care. The contract also says that there is a $0 copayment 
for days 8-90.  
 The record shows that the Medicare inpatient payment policies had not changed as a result of the Hospital 
without walls waiver. You have been asked to pay a total of $860, which is a $215 copayment per day for four 
days of inpatient hospital care ($215 copayment x 4 days = $860). There is no charge for the day of discharge. 
Inpatient hospital care falls within the Inpatient Hospital Care benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for inpatient hospital care provided from June 14, 2021, to June 18, 2021.
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 
March 12, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you cannot afford the copayment. 
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 $110 
copayment for each emergency room visit.  
 
You have been asked to pay a $110 copayment for the ER visit. The 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 March 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on November 12, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that this provider was not responsible to 
obtain authorization, and the assisted living facility is responsible to obtain prior authorization for all of their 
patients. The Plan denied your request. The Plan says this provider is out-of-network with the Plan, and 
authorization was not obtained prior to the services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a domiciliary or rest home visit provided on 
November 12, 2021, 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 the ER visit provided on November 20, 
2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you were advised you were admitted 
first under observation and later told you were admitted to the hospital. You feel that you were wrongfully 
billed. The Plan denied your request. The Plan says the copayment applied correctly. The records show that 
you were given an outpatient observation notice that specifically says you are not inpatient and that you are 
receiving observation services only.  
 
 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 each Medicare-covered emergency room visit worldwide.  
 
You have been asked to pay $50 for your ER visit. ER visits fall within the Emergency care benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the ER visit provided on November 20, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Home Health services provided on May 25, 2021 to June 25, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Home Health services. You say that you would like to appeal the denial of the 
claim. The Plan denied your request. The Plan says the provider is out-of-network and it was determined these 
services were not urgent or emergent. 
 
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 Home Health services provided on May 25, 2021 
to June 25, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 13, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the rendering provider and the referring provider are non-participating 
providers with the Plan. The Plan also says that they did not authorize any services for this facility or the 
referring 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 December 13, 2021, by 
an out-of-network (OON) provider.