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

 
We decided that the Plan does not have to waive the copayment for an echography (ultrasound) provided on 
June 7, 2022. 
 
You asked the Plan to waive the copayment for an echography (ultrasound). You say that you should not have 
to pay this large copayment. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You are being asked to pay a $115.82 copayment, rather than the full copayment of $150 for an echography 
(ultrasound). This item/service 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 an echography (ultrasound) 
provided on June 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76376 billed for date of service June 24, 
2022. 
 
You asked the Plan to pay for procedure code 76376. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 76376 is bundled into 
payment for code 77063. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76376 
is a column II code to column I code 77063. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76376 billed for date of service June 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic test provided on May 
23, 2022. 
 
You asked the Plan to waive the copayment for PET scan. You say that you were not expecting a copay for the 
PET scan. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $300 
copayment for PET scans/registry.  
 
You have been asked to pay $300 copayment for PET scan. This item/service falls within the PET 
scans/registry 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 outpatient diagnostic test 
provided on May 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a determination of refractive state (92015) provided on July 
14, 2022. 
 
You asked the Plan to pay for a determination of refractive state (92015). You say that it was hard to see what 
you were signing. You also say that you must have signed the wrong paperwork that they sent into the Plan. The Plan denied your request. The Plan says eye refractions are only covered by the Plan if performed by a 
participating provider and performed as a routine screening. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when performed by a Plan routine vision care provider during a 
routine exam. 
 
We looked at the file and the Plan's rules. The Plan rules say that these services are covered when provided 
during a routine exam. The record shows the charges were billed with a medical diagnosis for an eye refraction. 
Based on this information, we decided that the Plan's rules for coverage of a determination of refractive state 
(92015) have not been met. Therefore, we decided that the Plan does not have to pay for a determination of 
refractive state (92015) provided on July 14, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided from 
July 2, 2022, to July 3, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you don't believe you 
should pay the copayment. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for an emergency room visit. This item/service 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 from July 2, 2022, to July 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-rays provided on June 02, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for x-rays. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says the enrollees network primary care provider (PCP) or plan must give the enrollee 
approval in advance before they can use providers not in the plan's network. This is called giving you a 
"referral." 
 
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 x-rays provided on June 02, 2022, 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 CAT Scan provided on May 11, 2022. 
 
You asked the Plan to waive the copayment for a CAT Scan. You say that you do not believe you should pay 
because you unaware of the copayment. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for outpatient hospital services/diagnostic imaging.  
 
You have been asked to pay a $275 copayment for a CAT Scan. The total amount you are being asked to pay is 
$240.15 which is less than the required amount. 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 CAT Scan 
provided on May 11, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on October 26, 
2021. 
 
You asked the Plan to waive the copayment for emergency care. You say that no vitals were taken, did nothing 
for you, and should not be responsible for your emergency room copayment. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $90 
copayment for Medicare-covered visit.  
 
You have been asked to pay $90 copayment for emergency care. This item/service falls within the Medicare-
covered 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 emergency care provided 
on October 26, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on June 
6, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you don't believe you 
should pay the copayment because you were told to go to urgent care because the line was too long. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for in-network emergency care.  
 
You have been asked to pay a $90 copayment for an emergency room visit. This item/service falls within the 
in-network 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 June 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH admission is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
coverage of a LTACH admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no documentation provided indicating the medical necessity for an 
admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where he is 
currently receiving care. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis.  
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on April 26, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be covered. 
 
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 provided on April 26, 2022, 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 inpatient consultation provided on March 13, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an inpatient consultation. You say that this misunderstanding was due to the 
staff, not the provider. The Plan denied your request. The Plan says there was no preauthorization by a primary 
care provider (this is different than a referral) for an out-of-network (OON) provider or facility, and this was 
not an emergency. Therefore, the decision is upheld. 
 
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 inpatient consultation provided on March 13, 
2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for computed tomography (CT) scan on 
March 22, 2022, to April 04, 2022. 
 
You asked the Plan to waive the copayments for CT scan. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for each Medicare-covered CT scan. Covered services include but are not limited to other outpatient 
diagnostic tests. There were two visits. $250 x 2 = $500. Therefore, results in the total cost sharing amount of 
$500. 
 
 
 
 
 You have been asked to pay a $250 copayment for each CT scan. This item/service 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 
copayments for computed tomography (CT) scan on March 22, 2022, to April 04, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health provided on July 19, 2022, to 
August 02, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says the enrollees network primary care provider (PCP) or plan must give 
the enrollee approval in advance before they can use providers not in the plan's network. This is called giving 
you a "referral." 
 
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 outpatient mental health provided on July 19, 
2022, to August 02, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment and related 
supplies provided on January 20, 2022. 
 
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you are appealing 
the total cost share in the amount of $500.00 for services. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare-covered benefits. The allowed amount of durable medical equipment total $2,500.00, 
resulting in a coinsurance amount of $500.00. 
 
You have been asked to pay 20% coinsurance for durable medical equipment. This item/service falls within the 
Medicare-covered benefits 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 durable 
medical equipment and related supplies provided on January 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rest home visit provided on June 30, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the rest home visit. You say that it should be the nursing facility's responsibility 
to facilitate authorization. The Plan denied your request. The Plan says a referral/authorization was not 
obtained prior to 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 rest home visit provided on June 30, 2022, 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 (99213) provided on May 26, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not obtained. 
 
  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 (99213) provided on May 26, 2022, 
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 interventional cardiology visit provided on July 14, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an interventional cardiology visit. You say that this should be covered since the 
Plan and the medical center are in the same geographical location. The Plan denied your request. The Plan says 
there was no preauthorization by a primary care provider (this is different than a referral) for an out-of-network 
(OON) provider or facility, and this was not an emergency. Geographic location does not mean that the claim 
will be automatically covered. Therefore, the decision is upheld. 
 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 interventional cardiology visit provided on July 
14, 2022, by an out-of-network (OON) provider.