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

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on March 1, 
2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you already paid a copayment at 
the time of the visit, and that you should not have anything else due. The Plan denied your request. The Plan 
says the copayment applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for physician/practitioner services, Medicare-covered specialist visit.  
 
You have been asked to pay a $25 copayment for a specialist visit. A specialist visit falls within the 
Physician/Practitioner Services, Medicare-Covered Specialist Visit benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a specialist visit provided on March 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 8, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 22, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 
 The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a heart procedure provided on March 21, 
2022. 
 
You asked the Plan to waive the coinsurance for a heart procedure. You say that you should not have to pay 
this out-of-network provider, as you did not have a provider to do this in your town. The Plan denied your 
request. The Plan says the coinsurance 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 50% 
coinsurance for out-of-network outpatient surgery services. The allowed amount of this item is $342.11, 
resulting in a coinsurance amount of $171.05 ($342.11 / 50% = $171.05). 
 
You have been asked to pay a $171.05 coinsurance for a heart procedure. A heart procedure falls within the 
Out-Of-Network Outpatient Surgery 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 coinsurance 
for a heart procedure provided on March 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography scan provided on 
May 13, 2022. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you paid a copayment already at the 
time of this visit and should not owe anything else. The Plan denied your request. The Plan says the copayment 
applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $180 
copayment for Advanced Imaging Services.  
 
You have been asked to pay a $180 copayment for a CT scan. A CT scan falls within the Advanced Imaging 
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 computed tomography 
scan provided on May 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections on April 14, 2022. 
 
You asked the Plan to waive the coinsurance for injections. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Part B drugs, including chemotherapy drugs. These drugs are covered under Part B of Original 
Medicare. Members of our plan receive coverage for these drugs through our plan. Covered drugs include 
drugs that usually arent self-administered by the patient and are injected or infused while you are getting 
physician, hospital outpatient, or ambulatory surgical center services. The provider billed in the amount of 
$9,732 and the allowed amount is $3,662.96. $3,662.96 x 20% = $732.59. Therefore, results in the total cost 
sharing amount of $732.59. 
 
 
 
 You have been asked to pay a 20% coinsurance for injections. Injections 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 injections on April 
14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for monitoring services (95910, 95938, 95886) provided 
February 8, 2022. 
 
You asked the Plan to pay for the monitoring services. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the codes billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 95910, 95938, & 95886 are not supported in the medical record. Specifically, payment 
for these services is included in payment to the facility. Based on this information, we decided that Medicare 
rules for coverage of the monitoring services have not been met. Therefore, we decided that the Plan does not 
have to pay for monitoring services (95910, 95938, 95886) provided February 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for electrocardiogram (EKG) on March 10, 
2022. 
 
You asked the Plan to waive the copayment for electrocardiogram (EKG). You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says the cost sharing you are being charged is 
correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5 
copayment per day for Medicare-covered outpatient diagnostic tests. You will only pay one copayment per day 
even if multiple tests are performed. Covered services include but are not limited to other outpatient diagnostic 
tests. Includes but not limited to, sleep studies, EKG, stress tests, vascular studies, and breathing capacity tests. 
 
 
 You have been asked to pay a $5 copayment for electrocardiogram (EKG). Electrocardiogram (EKG) 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 electrocardiogram (EKG) on March 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a spinal injection provided on March 29, 
2022. 
 
You asked the Plan to waive the copayment for a spinal injection. You say that you have never received a 
copayment for injections prior to 2022 and would like the copayment to be reconsidered. The Plan denied your 
request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for all other outpatient services not provided in an ambulatory surgical center.  
 
You have been asked to pay a $275 copayment for a spinal injection. A spinal injection falls within 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 a spinal injection provided on 
March 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a diagnostic mammogram and ultrasound 
provided on April 7, 2022. 
 
You asked the Plan to waive the deductible for a diagnostic mammogram and ultrasound. You say that you 
went in for a mammogram and the technician was having a hard time getting full picture. You say that you do 
not feel like you should be required to pay for the second mammogram due to a technical issue. The Plan 
denied your request. The Plan says the deductible 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 there is a $225.99 deductible which applies to the amount you have to pay out-
of-pocket for all services until your $1,250 in-network and out-of-network deductible is met. 
 
The item or service you asked the Plan to waive the deductible for falls within the What is Your Plan 
Deductible benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $225.99 deductible for the diagnostic mammogram and ultrasound, ($102.19 + $123.80 = $225.99), 
which applies to the amount you have to pay out-of-pocket for all services until your $1,250 in-network and 
out-of-network deductible is met. This cost sharing is a contractual obligation that had not been met at the time 
a diagnostic mammogram and ultrasound was received on April 7, 2022. Therefore, we decided that the Plan 
does not have to waive the deductible for a diagnostic mammogram and ultrasound provided on April 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the services provided from February 17, 2021, to 
August 9, 2021. 
 
You asked the Plan to pay more for the services. You say that you overpaid toward your maximum out-of-
pocket for the 2021 Plan year. The Plan denied your request. The Plan says you paid the correct 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 the most you will have to 
pay out of pocket for in network covered Part A and Part B services in 2021 is $4,400.  
 
You were only asked to pay $4,399 toward your maximum out-of-pocket for the 2021 Plan year. 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 more for the services provided from February 17, 2021, to August 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88346, 88350) provided November 7, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 88346, & 88350 are not supported in the medical record. Specifically, per Local 
Coverage Article: MolDX: OncoCee Billing and Coding Guidelines (A55593), there is a more appropriate code 
for the testing performed. Based on this information, we decided that Medicare rules for coverage of the lab 
services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (88346, 
88350) provided November 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatment (97813, 97814) and the infrared 
therapy (97026) provided on October 22, 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 are not payable as the provider is 
not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the case file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the acupuncture treatment (97813, 
97814) and the infrared therapy (97026) provided on October 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 15, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 
 
 
 The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 15, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Part B drugs on July 08, 2021, to July 22, 
2021. 
 
You asked the Plan to waive the coinsurance for Part B drugs. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for each Medicare-covered Part B drug. These drugs are covered under Part B of Original 
Medicare. Members of our plan receive coverage for these drugs through our plan. Covered drugs include 
drugs that usually arent self-administered by the patient and are injected or infused while you are getting 
physician, hospital outpatient, or ambulatory surgical center services. For the date of service July 08, 2021, the 
allowed amount is $471.77. For date of service July 22, 2021, the allowed amount is $453.92. $453.92 + 
$471.77 = $925.69. Therefore, results in the total cost sharing amount of $925.69. 
 
 
 You have been asked to pay a 20% coinsurance for Part B drugs. Part B drugs fall within the Medicare Part B 
prescription drugs benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for Part B drugs on July 
08, 2021, to July 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and copayment for X-rays of the knee and a 
specialist office visit provided on April 12, 2022. 
 
You asked the Plan to waive the deductible and copayment for the X-rays and specialist visit. You say that you 
only saw the doctor for 10 minutes. The Plan denied your request. The Plan says the correct deductible amount 
and copayment were applied. 
 
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 $500 deductible which applies to certain items and services.  
 
X-rays fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The 
specialist visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $500 
deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not 
been met at the time the X-rays and specialist visit was received on April 12, 2022.  The file shows that you had a total of $135.08 remaining to meet your deductible. The allowed amount of 
$86.74 for the X-rays was applied first. Of the allowed amount of $173.69 for the specialist visit, the remaining 
$48.34 was applied to meet the $500 deductible. Once this amount was met, the $10 copayment was then 
applied. The total for the services is $145.08. 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 and copayment 
for X-rays of the knee and a specialist office visit provided on April 12, 2022.
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 
April 27, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you should not be billed for the 
services. 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 $90 
copayment for each emergency room visit. You do not pay this amount if you are admitted to the hospital 
within 24 hours for the same condition.  
 
The file does not show that you were admitted to the hospital following the ER visit. Therefore, you have been 
asked to pay a $90 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 April 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) on 
October 15, 2021. 
 
You asked the Plan to waive the copayment for magnetic resonance imaging (MRI). You say that this amount 
is excessive and if the insurance is not paying anything then why should you have to pay. The Plan denied your 
request. The Plan says the cost sharing you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment per day for other Medicare-covered diagnostic radiology services that are not ultrasounds. Covered 
services include, but are not limited to diagnostic radiology services, such as ultrasound, nuclear cardiac 
imaging, PET, MRI, and CT scan. The provider billed in the amount of $1,900 and the allowed amount is 
$300.70. This is less than the copayment amount. Therefore, results in the total cost sharing amount of $300.70. 
 
 You have been asked to pay a $300.70 copayment, which is less than the copayment for magnetic resonance 
imaging (MRI). Magnetic resonance imaging (MRI) 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 magnetic 
resonance imaging (MRI) on October 15, 2021.