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

 
We decided that the Plan does not have to pay for Laboratory services provided on December 17, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Laboratory services. You say that you can't afford to pay for the service. The 
Plan denied your request. The Plan says the provider is out-of-network and it was determined these services 
were not urgent or emergent. 
 
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 Laboratory services provided on December 17, 
2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the x-ray received on October 2, 2021. 
 
You asked the Plan to waive the deductible for the x-ray. You say that all the bills you are receiving are 
unexpected. The Plan denied your request. The Plan says the deductible has been applied 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, when out-of-network, 35% coinsurance for Medicare-covered x-rays 
after the deductible has been met.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that the $750 deductible applies to x-rays. This cost sharing is a contractual obligation 
that had not been met at the time the x-ray was received on October 2, 2021. Therefore, we decided that the 
Plan does not have to waive the deductible for the x-ray received on October 2, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cystourethroscopy provided on October 
22, 2021. 
 
You asked the Plan to waive the copayment for a cystourethroscopy. You say that you only get $358 a month 
from Social Security, which does not allow you to pay for these bills, and you would like the copayment 
written off as you do not have the means to pay. The Plan denied your request. The Plan says you were charged 
the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $550 
copayment for outpatient surgery in an outpatient hospital facility.  
 
You have been asked to pay a $550 copayment for outpatient surgery in an outpatient hospital facility for a 
cystourethroscopy. A cystourethroscopy falls within the 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 cystourethroscopy provided on October 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay, ultrasound and 
CT scan provided from October 6, 2021, to November 23, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay, ultrasound and CT scan. You say 
that the in-network hospital diagnosed you incorrectly so you had no choice but to go to an out-of-network 
hospital. The Plan denied your request. The Plan says the copayment was applied correctly. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment each day for days 1 to 6 for Medicare-covered hospital care and a $0 copayment for additional 
Medicare-covered days. Your contract with the Plan also clearly says that you must pay a $135 copayment for 
Medicare-covered radiological diagnostic services, not including x-rays, performed in a physicians office or at 
a free-standing facility. 
 
You have been asked to pay a total of 1,246.26 for the inpatient hospital stay, ultrasound and CT scan. 
 
Date of Service Service Allowed 
Amount 
Standard 
Copayment 
Member Liability 
October 6, 2021  October 
12, 2021 
Inpatient 
Hospital 
$6,371.98 $250 $1,000 
November 1, 2021 Ultrasound $493.03 $135 $135 
November 23, 2021 CT Scan $111.26 $135 $111.26 (allowed amount) 
TOTAL:    $1,246.26 
 
The inpatient hospital stay falls within the Inpatient Hospital Care benefit category. The ultrasound and CT 
scan falls within the Other outpatient diagnostic tests  Radiological diagnostic services, not including x-rays 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital stay, 
ultrasound and CT scan provided from October 6, 2021, to November 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vaccine services provided on November 1, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the vaccine services. You say that you were unaware that an approved referral 
was needed. The Plan denied your request. The Plan says the rendering provider is an OON provider and there 
was no approved authorization. Also, the service rendered was not urgent or emergent. 
 
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 the vaccine services provided on November 1, 
2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Prolia injection provided on December 
28, 2021. 
 
You asked the Plan to waive the coinsurance for a Prolia injection. You say that its ridiculous you are being 
charged for having the injection administered. The Plan denied your request. The Plan says the coinsurance 
was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for other Part B covered drugs.  
 You have been asked to pay $254.27 (allowed amount = $1,271.34 x 20%) for the Prolia injection. The 
injection falls 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 the Prolia injection provided on December 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on September 9, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says The rendering provider is a non-participating provider, and the referring 
provider involved in these services is a non-participating provider with the Plan. The Plan also says that they 
did not authorize any services for either the rendering or referring provider. 
 
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 provided on September 9, 2021, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a drug test provided on November 22, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a drug test. You say that you would like to request reconsideration for payment. 
The Plan denied your request. The Plan says the provider is out-of-network and authorization is required prior 
to an out-of-network visit. 
 
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 drug test provided on November 22, 2021 by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 30, 2021, by 
an OON provider. 
 
You asked the Plan to pay for the laboratory services. You say that the ordering physician sent the specimen to 
your laboratory for testing. The Plan denied your request. The Plan says the rendering and referring providers 
are both OON providers and there was no approved authorization. Also, the service rendered was not urgent or 
emergent. 
 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 the laboratory services provided on September 30, 
2021, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an external electrocardiographic recording 
up to 48 hours by continuous rhythm recording and storage provided on October 29, 2021. 
 
You asked the Plan to waive the copayment for an external electrocardiographic recording up to 48 hours by 
continuous rhythm recording and storage. You say that you disagree with having to pay both $45 copayments 
because nobody advised you that you would be charged a second time when you went next door to get patch 
and stress test. The Plan denied your request. The Plan says you were charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for for services received from all other specialists at an independent office.  
 
 You have been asked to pay a $45 copayment for an external electrocardiographic recording up to 48 hours by 
continuous rhythm recording and storage. An external electrocardiographic recording up to 48 hours by 
continuous rhythm recording and storage 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 an external 
electrocardiographic recording up to 48 hours by continuous rhythm recording and storage provided on 
October 29, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an echocardiography, transthoracic, real-time with image 
documentation (2D) provided on January 9, 2022. 
 
You asked the Plan to pay for an echocardiography, transthoracic, real-time with image documentation (2D). 
You say that the emergency medical services informed you that they were required to take you to the nearest 
emergency room, and your plan insurance card states, "emergency and urgently needed services are covered 
outside the Plan service area (but not outside of the U.S.)." The Plan denied your request. The Plan says that 
this decision is based on how the claim was submitted and processed, and this provider is not a contracted 
provider. The Plan also says the claim was not billed as an emergency room visit, and no authorization was 
received for the procedure. 
 
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson 
standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be 
such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of 
immediate medical attention would result in serious jeopardy to their health.  
 
We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with 
an average knowledge of medicine would reasonably expect the absence of immediate medical care to 
seriously jeopardize their health in this case. Therefore, we decided that the Plan has to pay for an 
echocardiography, transthoracic, real-time with image documentation (2D) provided on January 9, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay from November 4, 
2021, through December 3, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you do not receive enough 
monthly income to pay this bill. The Plan denied your request. The Plan says coinsurance 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 $390 
copayment per day for days 1 through 5 per benefit period and $0 copayment for each additional day. 
 
  You have been asked to pay $1,950 for the inpatient stay ($390/day x 5 days = $1,950). The inpatient hospital 
stay falls 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 inpatient hospital stay from November 4, 2021, through December 3, 2021.
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 
December 14, 2021, to December 20, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that money is very tight 
right now and you just had to retire because of all your medical problems. The Plan denied your request. The 
Plan says the copayment was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $175 
copayment each day for days 1 - 7 per admission and a $0 copayment each day for days 8 - 90 per admission. You have been asked to pay a total of $1,050 ($175 copay x 6 days) for an inpatient hospital stay. An inpatient 
hospital stay falls 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 December 14, 2021, to December 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 4, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the patient does not go to your lab, so he/she is 
not using out-of-network benefits as his/her participating doctor sends you the specimen(s) to process. The Plan 
denied your request. The Plan says this provider is not a network provider with the Plan, and they have also 
determined that these services are not urgent or emergent, nor were they 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 laboratory services provided on January 4, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory work provided on December 17, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory work. You say that you have not been sent a bill to pay, but you 
cannot afford to take this bill. The Plan denied your request. The Plan says no prior authorization was 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 laboratory work in this appeal. The Plan did not pre-approve the 
laboratory work. We found no exception that would require the Plan to pay for the laboratory work. Therefore, 
we decided that the Plan does not have to pay for the laboratory work provided on December 17, 2021, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the diagnostic test provided on July 13, 
2021, and January 6, 2022. 
 
You asked the Plan to waive the copayments for the diagnostic test. You say that it was medically necessary to 
get the test done and it should be included in your office visit. The Plan denied your request. The Plan says the 
proper copayments were 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 $30 
copayment for Specialty Physician for other Medicare-covered outpatient diagnostic tests. The total allowed 
amount for each date was $11.41 which is less than the copayment amount of $30 therefore only $11.41 was 
charged a copayment for each date. The total copayment amount for both dates was $22.82 ($11.41 copayment 
amount + $11.41 copayment amount). 
 
You have been asked to pay a $22.82 copayment for the diagnostic test. The diagnostic test 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 the diagnostic test provided on July 13, 2021, and January 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the electrocardiogram (93000) provided on 
February 10, 2022. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for diagnostic procedures and tests.  
 
 You have been asked to pay $13.50 for the diagnostic test provided. This is the Plans allowed amount for this 
service, which is less than the applicable copayment. 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 electrocardiogram (93000) provided on February 10, 2022.