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

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (ECG) (93000) 
provided on December 7, 2021. 
 
You asked the Plan to waive the copayment for an electrocardiogram (ECG). You say that you had a physical, 
which included a routine electrocardiogram (EKG). You also say that according to your benefits this should 
have been a zero cost, and you see that you are being charged for the EKG. 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 an annual routine physical exam includes comprehensive physical examination and evaluation of status of chronic diseases, and 
does not include laboratory tests, radiological diagnostic tests or non-radiological diagnostic tests. Your 
contract with the Plan also says that enrollees must pay a $30 copayment for Medicare-covered non-
radiological diagnostic services.  
 
You have been asked to pay $16.13, which is less than the $30 copayment for an electrocardiogram (ECG). An 
electrocardiogram (ECG) falls within the Medicare-covered non-radiological diagnostic 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 an electrocardiogram (ECG) (93000) provided 
on December 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that the requested Injectafer is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Infed and Venofer first. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Injectafer. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of Infed 
and Venofer first before they will approve the requested drug. In this case, the enrollee has not tried and failed 
the required drug(s). There is no documentation provided indicating that the Plans required drug(s) would 
likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a chest x-ray provided on November 23, 
2021. 
 
You asked the Plan to waive the copayment for a chest x-ray. You say that the diagnostic radiology was part of 
an emergency diagnostic which was followed by being transferred to a different hospital. You also say that the 
Plan should cover the diagnostic radiology charge. 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 $60 
copayment for standard x-ray services.  
 
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$60 copayment for a chest x-ray. A chest x-ray 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 chest x-
ray provided on November 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance service, advanced life support, 
emergency transport, level 1 (A0427) provided on October 20, 2021. 
 
You asked the Plan to waive the copayment for ambulance service, advanced life support, emergency transport, 
level 1. You say that this was a coronavirus (COVID-19) emergency. 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 $250 
copayment for each one-way Medicare-covered ground trip ambulance service.  
 
 You have been asked to pay a $250 copayment for ambulance service, advanced life support, emergency 
transport, level 1. Ambulance service, advanced life support, emergency transport, level 1 falls within 
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 service, 
advanced life support, emergency transport, level 1 (A0427) provided on October 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on October 8, 2021. 
 
You asked the Plan to pay for the lab testing. You say that this lab testing cannot be denied because it is related 
to COVID-19. This means it must be covered regardless of network status. The Plan denied your request. The 
Plan says this claim was denied as the laboratory did not have an active CLIA accreditation on the date of 
service. 
 The Plan must follow Medicare rules. Medicare rules say that laboratories are required to have an active CLIA 
accreditation or certificate of waiver in order to receive payment from Federal programs.  
 
In this case, we find that the CLIA accreditation for this lab did not go into effective until November 3, 2021. 
As these lab services were provided before that date, the claim was correctly denied. Therefore, we decided that 
the Plan does not have to pay for the laboratory testing provided on October 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a physical therapy visit provided on May 4, 
2021. 
 
You asked the Plan to waive the copayment for the physical therapy visit. You say that you would like the Plan 
to waive the copayment. The Plan denied your request. The Plan says the proper copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for each Out of Network Medicare-covered visit.  
 
  You have been asked to pay a $50 copayment for the physical therapy visit. The physical therapy visit 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 copayment 
for a physical therapy visit provided on May 4, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the hearing aid check provided on November 18, 
2021. 
 
You asked the Plan to waive the copayment for the hearing aid check. You say that the EOC says one hearing 
aid fitting per year for no cost. The Plan denied your request. The Plan says that the copayment applied is 
correct. 
 
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 enrollees must pay a $0 copayment for hearing aid fitting evaluation every year.  
 
The Plan says you must pay a $35 copayment for the hearing aid check. Based on the Plan contract, however, 
you cannot be asked to pay more than a $0 copayment for the hearing aid check. Therefore, we decided that the 
Plan has to waive the copayment for the hearing aid check provided on November 18, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
November 3, 2021. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you were transported to 
another hospital so you should not be responsible for the copayment. The Plan denied your request. The Plan 
says medical documentation verified you were seen in the emergency department and claim history confirmed 
there was no other hospital admission within 24 hours. Therefore, the proper copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for each covered emergency room visit. If you are admitted to the hospital within 24 hours, you do 
not have to pay the $90 copayment.  
 
  You have been asked to pay a $90 copayment for the emergency room visit. The 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 November 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an office visit provided on May 4, 2021. 
 
You asked the Plan to waive the coinsurance for an office visit. You say that you went in for a wellness visit. 
The Plan denied your request. The Plan says the services rendered during the visit were not routine for a 
wellness visit, thus an office visit was charged. 
 
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 services obtained from a primary care provider.  
 
 
 
 
 
 
 You have been asked to pay $27.55 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 coinsurance 
for an office visit provided on May 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
September 15, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the insurance 
should pay more on the claim. The Plan denied your request. The Plan says the proper copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment for each one-way Medicare covered trip.  
 
  You have been asked to pay a $300 copayment for the ambulance transportation. The ambulance transportation 
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 
the ambulance transportation provided on September 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist telehealth visit provided on 
December 16, 2020. 
 
You asked the Plan to waive the copayment for specialist telehealth visit. You say that the provider took a year 
to bill you. The Plan denied your request. The Plan says the copayment 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 $45 
copayment for visits to specialists, including brief virtual (for example, via telephone or video chat) 5-10 
minute check-ins with your doctor - if you are an established patient and the virtual check-in is not related to an 
office visit within the previous 7 days, nor leads to an office visit within the next 24 hours or soonest available 
appointment.  
 
You have been asked to pay a $15.11 copayment for specialist telehealth visit. Specialist telehealth visits fall 
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 specialist telehealth visit provided on December 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services rendered by the out-of-network (OON) 
provider on June 17, 2021. 
 
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. 
 
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 medical services rendered by the out-of-network (OON) provider on June 17, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a K3 foot prosthesis (L5981, L5986). 
 
You asked the Plan to pre-approve the K3 foot prosthesis. You say that the prosthesis is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of foot. 
 
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 the K3 foot prosthesis. Our reviewer 
says that the requested foot is not medically necessary. Our physician reviewer found the provided 
documentation does not clearly show the patient currently is at a K3 level of activity to justify the K3 foot. The 
prescribing physician also did not explain the reason this was needed over a regular prosthesis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the K3 foot prosthesis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a K3 foot prosthesis (L5981, L5986).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an Ultrasound on November 11, 2021. 
 
You asked the Plan to waive the deductible for an Ultrasound. You say that you would like the plan to pay the 
bill. The Plan denied your request. The Plan says the cost share was 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 $500 
deductible for Ultrasound. At the time this claim was processed, $301.03 of the $500 deductible had been met. 
Because the deductible hadnt been met prior to the service the full allowed amount of $126.50 was 
applied correctly. 
 
You have been asked to pay a $500 deductible for an Ultrasound. An Ultrasound falls within the Other 
outpatient diagnostic tests  Radiological diagnostic services, not including x-rays 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 an Ultrasound on November 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound of the breast (76642) rendered by the out-of-
network (OON) provider on December 8, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the ultrasound of the breast (76642) rendered by the out-of-network (OON) provider 
on December 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for arthroplasty, interposition, intercarpal or 
carpometacarpal joints (25447) provided on April 22, 2021. We also decided that the Plan does not have to 
waive the copayment for an office visit (99215) and an x-ray exam of hand (73120) provided on July 30, 2021. 
 
You asked the Plan to waive the copayment for arthroplasty, interposition, intercarpal or carpometacarpal joints 
and an office visit and an x-ray exam of hand. You say that you were billed for having pins taken out of your 
finger and you should not have to pay because you cannot remove the pins yourself. 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 $225 
copayment for each Medicare-covered ambulatory surgical center surgery. Your contract with the Plan also 
says that enrollees must pay a $25 copayment for Medicare-covered x-rays after the deductible is met. You 
contract with the Plan also says that enrollees must pay a $30 copayment for each Medicare-covered specialist 
visit in person or by telehealth.  
 
You have been asked to pay a $225 copayment for arthroplasty, interposition, intercarpal or carpometacarpal 
joints. Arthroplasty, interposition, intercarpal or carpometacarpal joints falls within the outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. 
You have also been asked to pay a total of $30 for an office visit and an x-ray exam of hand ($25 copayment 
for an x-ray of the hand and $5 copayment for an office visit = $30). An office visit falls within 
physician/practitioner services, including doctor's office visits benefit category. An x-ray exam of hand 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 arthroplasty, interposition, intercarpal or carpometacarpal joints 
(25447) provided on April 22, 2021. We also decided that the Plan does not have to waive the copayment for 
an office visit (99215) and an x-ray exam of hand (73120) provided on July 30, 2021.