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

 
We decided that the Plan does not have to pay for office visit services provided on February 23, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for office visit 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 office visit services provided on February 23, 
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 an electrocardiogram (EKG) on November 
29, 2021. 
 
You asked the Plan to waive the copayment for an electrocardiogram (EKG). You say that you would like to 
appeal the cost share. The Plan denied your request. The Plan says the correct copayment due from seeing a 
Primary Care Physician for an EKG is $5. 
 
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 $5 
copayment for each diagnostic test from a Primary Care Physician for an electrocardiogram.  
 
You have been asked to pay a $5 copayment for each diagnostic test from a Primary Care Physician for an 
electrocardiogram (EKG). An electrocardiogram (EKG) falls within the Inpatient stay: Covered services 
received in a hospital or SNF during a non-covered inpatient stay 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 electrocardiogram (EKG) on November 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the out-of-network (OON) office visit 
provided on November 3, 2021. 
 
You asked the Plan to waive the deductible for the OON office visit. You say that you disagree with the denial. 
The Plan denied your request. The Plan says the amount 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 
deductible for OON practitioner office visits.  
 
 
 
 
 You have been asked to pay $98.72 towards your deductible for the OON 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 deductible for the out-of-network (OON) office visit provided on November 3, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an influenza virus vaccine provided on October 22, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for an influenza virus vaccine. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says this provider is not a network provider with the Plan, and 
the services were not referred by a network provider. The Plan also says that they have also determined that 
these services are not urgent or emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan 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 influenza virus vaccine provided on October 
22, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a fluorodeoxyglucose (contrast agent) 
injection provided on June 16, 2021. 
 
You asked the Plan to waive the deductible for the contrast injection. You say that you would like the bill for 
the contrast agent removed. The Plan denied your request. The Plan says the correct amount has been 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 $750 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for 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 $750 deductible which applies to certain items and services. This cost 
sharing is a contractual obligation that had not been met at the time the contrast injection for the PET scan was 
received on June 16, 2021. Therefore, we decided that the Plan does not have to waive the deductible for a 
fluorodeoxyglucose (contrast agent) injection provided on June 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided 
from September 20, 2021, to September 21, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say this matter is of great 
concern to you, and you would like it investigated. 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 $350 
in-network copayment per day, days 1 to 5 for inpatient hospital care.  
 
 
  You have been asked to pay $350 for the inpatient hospital services. The inpatient hospital services fall within 
the Inpatient hospital care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient 
hospital services provided from September 20, 2021, to September 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for injection(s), of diagnostic or therapeutic 
substances provided from November 1, 2021, to January 12, 2022. 
 
You asked the Plan to waive the copayment for injection(s), of diagnostic or therapeutic substances. You say 
that you are on a limited income. You also say that you will have no quality of life without the injections as you 
can hardly walk without them, but cannot afford the $275 copayments. The Plan denied your request. The Plan 
says you were 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 $275 
copayment per visit, per provider, per day for surgery performed in an outpatient hospital setting.  
 You have been asked to pay a total of $550 for two visits for injection(s), of diagnostic or therapeutic 
substances ($275 x 2 = $550). Injection(s), of diagnostic or therapeutic substances fall within the outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for injection(s), of diagnostic or therapeutic 
substances provided from November 1, 2021, to January 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
thorax provided on December 13, 2021. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan of the thorax. You say that 
this is a low dose CT scan, and since you have had cancer and smoked for 50 years before the cancer, you 
should not have to pay for this claim. You also say that this is a burden on you. 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 $160 
copayment for Medicare-covered radiological diagnostic services not including x-rays, performed in a 
physician's office or at a free-standing facility (such as a radiology center or medical clinic). You have been asked to pay $106.36, which is less than the $160 copayment for a computed tomography (CT) 
scan of the thorax. A computed tomography (CT) scan of the thorax 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 of the thorax provided on December 13, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the physical therapy visits provided from 
December 20, 2021, to December 29, 2021. 
 
You asked the Plan to waive the copayments for the physical therapy visits. You say that you were unaware 
that there would be a copayment for the service provided. The Plan denied your request. The Plan says 
documentation provided shows the enrollee received the services during the dates of service. Therefore, the 
proper copayments were 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 per therapy type, per provider, per day for physical and speech services. From December 20, 2021, 
to December 29, 2021, there was a total of 4 visits to the provider for services. The total copayment amount for 
the 4 visits was $140 ($35 copayment x 4 visits).  
 
You have been asked to pay a $140 copayment for the physical therapy visits. The physical therapy visits falls 
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 copayments 
for the physical therapy visits provided from December 20, 2021, to December 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an arthrocentesis provided on November 
11, 2021. 
 
You asked the Plan to waive the copayment for an arthrocentesis. You say that you want the plan to pay for this 
procedure in full as this has been paid in the past for the same procedure. 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 $370 
copayment for outpatient surgery at an outpatient hospital.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
the allowed amount of $251.56, which is less than the $370 copayment for an arthrocentesis. An arthrocentesis falls within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an 
arthrocentesis provided on November 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on October 7, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that you were not aware of the requirement of obtaining a 
prior authorization, specifically for this member's plan type at the time of rendering services. 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. 
 
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 drug testing provided on October 7, 2021, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Prolia injection (a Medicare Part B 
prescription drug) provided on December 21, 2021. 
 
You asked the Plan to waive the coinsurance for the Part B drugs. You say that you feel you should not have to 
pay more for the coinsurance than what the provider billed. The Plan denied your request. The Plan says the 
coinsurance amount 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 20% of 
the cost for Medicare Part B chemotherapy drugs and other Part B drugs. The allowed amount totaled 
$1,374.62, resulting in a total coinsurance amount of $274.92.  
 
 
  You have been asked to pay 20% of the cost 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 the Prolia injection 
(a Medicare Part B prescription drug) provided on December 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided on October 5, 2021 to 
October 20, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for inpatient hospital care. You say that authorization is not the providers' 
responsibility. The Plan denied your request. The Plan says the services were provided out-of-network and 
were not approved in advance. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 inpatient hospital care provided on October 5, 
2021 to October 20, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on October 1, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. You say that you were issued a referral by your provider in April 
2021 to April 2022. The Plan denied your request. The Plan says this provider is not a network provider with 
the Plan and the services were not referred by a network provider or rendered in an in-network facility. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 psychotherapy provided on October 1, 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 breast ultrasound provided on January 28, 
2022. 
 
You asked the Plan to waive the copayment for a breast ultrasound. You say that this should be covered in full 
as it was part of a breast cancer screening. You also say that you did not even see the doctor. 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 $55 copayment for an ultrasound. The Plan contract also says that breast cancer screening covers one screening 
mammogram every 12 months at no cost share. The contract also says that additional testing may require an 
additional copayment. 
 
The record shows a copayment has been applied correctly for a breast ultrasound that took place during your 
screening mammogram on January 28, 2022. You have been asked to pay a $55 copayment for a breast 
ultrasound. A breast ultrasound 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 breast ultrasound 
provided on January 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for duplex scans (ultrasounds) of extremity 
veins provided on November 23, 2021, and November 24, 2021. 
 
You asked the Plan to waive the copayments for the ultrasounds. You say that you should not have to pay two 
copayments since it was not your fault that they could not complete the tests in one day. 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 diagnostic procedures and tests, including ultrasounds.  
 
You have been asked to pay a $50 copayment for each of the ultrasounds, for a total of $100. The 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 copayments for duplex scans (ultrasounds) of extremity veins provided on 
November 23, 2021, and November 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physiologic studies provided on August 20, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for physiologic studies. 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 physiologic studies provided on August 20, 2021 
by an out-of-network (OON) provider.