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

 
We decided that the Plan does not have to waive the copayments for the emergency room visit, and urethra 
endoscope provided from September 27, 2022, to October 6, 2022. 
 
You asked the Plan to waive the copayments for the emergency room visit and urethra endoscope. You say that 
you should not have to pay these charges due to the quality of care you received. 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 room visits. You contract with the Plan also clearly states that you must pay a $250 copayment for each in-network outpatient surgery provided at an outpatient hospital.  
 
You have been asked to pay a $90 copayment for the emergency room visit. This item/service falls within the 
emergency care benefit category. You have also been asked to pay a $250 copayment for the urethra 
endoscope. This item/service falls within the outpatient surgery benefit category. You have been asked to pay a 
total of $340 ($90 copayment + $250 copayment = $340). This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments 
for the emergency room visit, and urethra endoscope provided from September 27, 2022, to October 6, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the ambulance transportations provided 
from October 28, 2022, to December 5, 2022. 
 
You asked the Plan to waive the copayments for the ambulance transportations. You say that you should not 
have been transported and should not be held responsible. 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 $290 copayment for each ambulance service.  
 
You have been asked to pay a $290 copayment for each ambulance service. These items/services fall 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 copayments for the ambulance 
transportations provided from October 28, 2022, to December 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the office visit provided on October 15, 
2022. 
 
You asked the Plan to waive the deductible for the office visit. You say that this office did not provide annual 
wellness visits, so you had to make a regular office visit. 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. Your 
contract with the Plan says that there is a $100 deductible which applies to in-network and out-of-network 
office visits.  
 
The item or service you asked the Plan to waive the deductible for falls within the physician/practitioner services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $100 deductible which applies to in-network and out-of-network office visits. This cost sharing is a 
contractual obligation that had not been met at the time the office visit was received on October 15, 2022. 
Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided on 
October 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
February 18, 2020, to February 20, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you are on a fixed 
income and cannot afford this 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 $350 
copayment per day for days 1-5 of each in-network inpatient hospital stay.  You have been asked to pay a $350 copayment per day for days 1-2 of the inpatient hospital stay. You have not 
been charged for the day you were discharged. The total you have been asked to pay is $700 ($350 copayment 
per day x 2 days = $700). These items/services fall within the inpatient hospital care benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the inpatient hospital stay provided from February 18, 2020, 
to February 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the outpatient clinic visit provided on 
October 14, 2022. 
 
You asked the Plan to reduce the copayment for the outpatient clinic visit. You say that you have only ever had 
to pay a $35 copayment for this appointment. 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 $85 
copayment for in-network outpatient hospital services. 
 
You have been asked to pay a $85 copayment for the outpatient clinic visit. This item/service falls within the 
in-network outpatient hospital 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. The records show this claim was submitted by an outpatient hospital 
facility. Therefore, we decided that the Plan does not have to reduce the copayment for the outpatient clinic 
visit provided on October 14, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF care provided from September 26, 
2022, to October 29, 2022. 
 
You asked the Plan to waive the copayment for SNF care. You say that the member reached their out-of-pocket 
costs at the time services were rendered. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $0 copayment for days 1 to 20 and a $188 copayment for days 21 to 100 for SNF care.  
 
 
  The enrollee has been asked to pay $1,734.08, which is less than the standard copayment for SNF care. The 
maximum out-of-pocket was met with the processing of this claim causing the amount to be less. This 
item/service falls within the SNF care benefit category. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for SNF care provided from September 26, 2022, to October 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213). 
 
You asked the Plan to pre-approve the dental services. You say that you are unable to use the right side of your 
mouth. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 28, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontic  porcelain/ceramic (D6245) Tooth #9,10,12,15, 
and retainer crown  porcelain/ceramic (D6740) Tooth #11,14. 
 
You asked the Plan to pre-approve the dental services. You say that you need the requested services approved. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. This benefit includes the 
requested pontic  porcelain/ceramic (D6245) and retainer crown  porcelain/ceramic (D6740) but is limited up 
to four units of fixed dentures per year, covered one per tooth per life. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you were pre-approved for pontic  porcelain/ceramic (D6245) Tooth #7, 8, and retainer crown  
porcelain/ceramic (D6740) Tooth #5, 6; therefore, your benefits have been exhausted. Therefore, we decided 
that the Plan does not have to pre-approve pontic  porcelain/ceramic (D6245) Tooth #9,10,12,15, and retainer 
crown  porcelain/ceramic (D6740) Tooth #11,14.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Medicare Part B prescription drugs and a 
specialist office visit provided on December 29, 2022. 
 
You asked the Plan to waive the cost share for Medicare Part B prescription drugs and a specialist office visit. 
You say that you disagree with the cost share. 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 20% 
coinsurance for Medicare Part B prescription drugs and a $40 copayment for physician/practitioner 
services/specialist.  You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs and a $40 copayment 
for a specialist office visit. The total allowed amount for the prescription drugs is $8.72. You are being asked to 
pay $1.74 ($8.72 x 20% = $1.74). The total amount for all services is $41.74 ($40 + $1.74 = $41.74). This 
item/service falls within the Medicare Part B prescription drugs and physician/practitioner services/specialist 
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 cost share for Medicare Part B prescription 
drugs and a specialist office visit provided on December 29, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the specialist visit provided by an in-network provider 
on December 8, 2022, and December 15, 2022. 
 
You asked the Plan to waive the copayment for the specialist visits. You say that you already met your out-of-
pocket maximum. The Plan denied your request. The Plan says that this cost sharing was charged correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not differentiate between in-network and out-of-network claims in 
the breakdown of your out-of-pocket maximum costs. Therefore, we decided that the Plan has to waive the 
copayment for the specialist visit provided by an in-network provider on December 8, 2022, and December 15, 
2022.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on 
December 7, 2022. 
 
You asked the Plan to waive the copayment for the lab services. You say that these charges should be waived 
when you are having an office visit on the same day. 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 $10 copayment for Medicare-covered laboratory tests.  
 
You have been asked to pay a $10 copayment for the lab services. These items/services fall within the 
outpatient diagnostic tests and therapeutic 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 laboratory services provided on December 7, 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 the enrollee needs LTACH care. The 
Plan denied your request. The Plan says criteria for admission to the LTACH have not been met. 
 
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 the enrollee is receiving appropriate care at the present acute care hospital. 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 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 waive the coinsurance for the radiation therapy services provided 
from November 28, 2022, to December 23, 2022. 
 
You asked the Plan to waive the coinsurance for the radiation therapy. You say that you believe you had 
already met your out-of-pocket maximum for the year. 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 per visit for radiation therapy.  
 
The records show that your out-of-pocket maximum was met during the processing this claim. You have been 
asked to pay a total $1,311.94 for the radiation therapy. These items/services fall within the outpatient 
diagnostic tests and therapeutic 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 the radiation therapy services provided from November 28, 2022, to December 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CTA scan of the upper extremity 
 
You asked the Plan to pre-approve CTA scan of the upper extremity. You say that the enrollee would like 
reconsideration because the services are medically necessary. The Plan denied your request. The Plan says a 
CTA scan of the upper extremity is not medically necessary 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CTA scan of the upper extremity. Our 
reviewer says that the requested CTA scan of the upper extremity is not medically necessary. Our physician 
reviewer found that during the enrollee's visit on December 27, 2022, they were found to have swelling above 
their elbow, however an upper extremity venous or arterial ultrasound was not done. The tests can evaluate 
both the arteries and veins of the upper extremity in the face of soft tissue swelling. The requested CTA would 
only evaluate the arteries and not the deep veins of the upper extremity. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CTA scan of the upper extremity have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a CTA scan of the upper extremity
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
November 26, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that this should be covered 
under emergency care. 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 one-way ground ambulance services. 
 
You have been asked to pay a $250 copayment for the ambulance services. This item/service falls within the 
one-way ground 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 services provided on November 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 17, 2022, to December 
10, 2022. 
 
You asked the Plan to pay for an office visit. You say that you called the appeals department and was told you 
are a participating provider. The Plan denied your request. The Plan says that unauthorized, out-of-network 
care is not 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on September 17, 2022, to December 10, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the ultrasound provided on November 02, 
2022. 
 
You asked the Plan to reduce the copayment for the ultrasound. You say that the Plan did not cover the 
ultrasound. 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 $115 
copayment for in-network outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $115 copayment for the ultrasound. This item/service falls within the in-network 
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. However, since the allowed amount is less than the 
standard copayment, you only owe $78.09. Therefore, we decided that the Plan does not have to reduce the 
copayment for the ultrasound provided on November 02, 2022.