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

 
We decided that the Plan does not have to pay for the shingles vaccine received on October 6, 2021. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the services. 
Therefore, we decided that the Plan does not have to pay for the shingles vaccine received on October 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) scan 
provided on December 13, 2021. 
 
You asked the Plan to waive the copayment for the MRI scan. You say that you did not know the copayment 
would be this much and if you did you would have never scheduled the appointment. The Plan denied your 
request. The Plan says they reviewed the records, and an MRI scan was done on the date of service. 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 $325 
copayment for Medicare-covered diagnostic radiology services that are not ultrasounds.  
 You have been asked to pay a $325 copayment for the MRI scan. The MRI scan 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 magnetic resonance imaging (MRI) scan provided on December 13, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic imaging provided on 
November 1, 2021. 
 
You asked the Plan to waive the copayment for the diagnostic imaging. You say that you have had this test 
done prior and the copayment should not be for an outpatient facility because it is a doctor's office. The Plan 
denied your request. The Plan says the proper copayment was applied for the service that was billed. 
 
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 each Medicare-covered diagnostic radiology.  
 
  You have been asked to pay a $275 copayment for the diagnostic imaging. The diagnostic imaging 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 the diagnostic imaging provided on November 1, 2021.
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 
maxillofacial area provided on December 1, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you believe the billing was incorrect 
and the Plan did not pay anything for the service. 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 $275 
copayment for advanced imaging services provided at an outpatient hospital, including CT scans.  
 
You have been asked to pay $184.11, which is less than the $275 copayment for the CT scan. Please note that the Plan covers costs in excess of your copayment amount. In this case, the allowed amount for this procedure 
was less than the copayment, therefore you are only responsible for the lesser amount. The CT scan 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 maxillofacial area provided 
on December 1, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist services provided on August 
19, 2021. 
 
You asked the Plan to waive the copayment for the specialist services. You say that the billing was wrong and 
confusing. 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 $40 
copayment for Physician specialist services (including surgery second opinion, telehealth, and urgently needed 
services).  
 
  You have been asked to pay a $40 copayment for the specialist services. The specialist services falls within the 
Physician/Practitioner services, including doctors office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the specialist services provided on August 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0480) provided on November 1, 2021, by an 
out-of-network provider. 
 
You asked the Plan to pay for drug testing. You say that the service at issue was a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for payment for out-of-network care have not been 
met. 
 
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 (G0480) provided on November 1, 
2021, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on 
October 11, 2021. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that you already paid one 
provider for the laboratory service you should not have to pay another provider for it. The Plan denied your 
request. The Plan says the proper copayment was applied for the service that was billed. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment per day, per provider, for Medicare-covered lab services.  
 
  You have been asked to pay a $20 copayment for the laboratory services. The laboratory services 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 the laboratory services provided on October 11, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a breath hydrogen/methane test provided 
by an out-of-network provider on December 4, 2020. 
 
You asked the Plan to waive the coinsurance for the breath hydrogen/methane test. You say that you had the 
test done and then had to go elsewhere to get the diagnosis for the test. The Plan denied your request. The Plan 
says you have been asked to pay 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 20% 
coinsurance for laboratory tests.  
 
 You have been asked to pay $39 which is 20% of the allowed amount for the breath hydrogen/methane test. 
The allowed amount is $195. ($195 x 20% = $39). The breath hydrogen/methane test falls within the 
Outpatient diagnostic tests and therapeutic services and supplies category. The record shows the claim was 
paid at the in-network benefit level.  
 
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 breath hydrogen/methane test provided by an out-of-
network provider on December 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lymphedema treatment services (29581, 97016, 97140) 
to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve lymphedema treatment services. You say that the requested services are a 
medical necessity for you. The Plan denied your request. The Plan says rules for coverage for out-of-network 
services have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
lymphedema treatment services (29581, 97016, 97140) to be provided by an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy visits to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the physical therapy visits. You say that the surgeon that did your surgery 
referred you to the out-of-network provider for physical therapy. The Plan denied your request. The Plan says 
they have redirected the enrollee to an in-network provider that provides the same quality of service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy visits to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 14, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that due to the short amount of time you were unable to 
get authorization. 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 an office visit provided on July 14, 2021, 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 a continuous positive airway pressure 
(CPAP) machine and supplies provided on April 22, 2021, May 22, 2021, and July 22, 2021. 
 
You asked the Plan to waive the coinsurance for a CPAP machine and supplies. You say that you were not 
satisfied with the machine and turned it in and received a new machine from a different supplier. The Plan 
denied your request. The Plan says the proper coinsurance was applied for the months the enrollee had the 
machine. 
  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 item. For April 22, 2021, the total amount allowed for the CPAP and 
supplies was $389.70 with a coinsurance of $77.94 ($389.70 total amount x 20%). For May 22, 2021, the total 
amount allowed was $39.70 with a coinsurance of $7.94 ($39.70 total amount allowed x 20% coinsurance). For 
July 22, 2021, the total amount allowed was $39.70 with a coinsurance of $7.94 ($39.70 total amount allowed x 
20% coinsurance). The total amount of the coinsurance for the dates of service was $93.82. 
 
You have been asked to pay a 20% coinsurance for a CPAP machine and supplies. The CPAP machine and 
supplies falls within the Durable medical equipment (DME) and related 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 coinsurance for a continuous positive airway pressure (CPAP) machine and supplies 
provided on April 22, 2021, May 22, 2021, and July 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for X-rays of the ribs provided on October 7, 
2021. 
 
You asked the Plan to waive the deductible for the X-rays. You say that the X-rays were ordered due to your 
pain and you would like the Plan to cover the charges. The Plan denied your request. The Plan says the correct 
amount was applied to your deductible. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $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 X-rays were taken on October 7, 2021. 
Therefore, we decided that the Plan does not have to waive the deductible for X-rays of the ribs provided on 
October 7, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a nerve conduction study performed on 
November 12, 2021. 
 
You asked the Plan to waive the copayment for the nerve conduction study. You say that you should not have 
to pay for the test as it was only partially completed. 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 $35 
copayment for outpatient diagnostic tests with a specialist.  
 
You have been asked to pay a $35 copayment for the nerve conduction study. The nerve conduction study 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 nerve conduction study performed on November 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on October 
14, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you were informed that 
the provider was in network and you should only have the $30 copayment. The Plan denied your request. The 
Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $55 
copayment for each out-of-network (OON) specialist visit.  
 
The file shows that the Plan verified the provider was out of network. Therefore, you have been asked to pay a 
$55 copayment for the specialist office visit. The specialist office visit falls within the Physician/Practitioner Services, Including Doctor's 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 a specialist office visit provided on October 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve back brace to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve back brace. You say that the back brace is necessary to help with mobility 
and lower back and hip pain. The Plan denied your request. The Plan says the services can be provided in-
network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
back brace to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you have seen this doctor before and would like 
to see them again. The Plan denied your request. The Plan says the services can be provided in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
November 10, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you went to see the new 
physician at the office, and it seemed like there was no purpose for the appointment. The Plan denied your 
request. The Plan says they reviewed the records and they determined that there was an office visit rendered 
with a specialist. 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 $15 
copayment for each covered visit or consultation in an outpatient location with a specialist.  
 You have been asked to pay a $15 copayment for the specialist office visit. The specialist office visit falls 
within the Physician/Practitioner services, including doctors office Visits benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a specialist office visit provided on November 10, 2021.