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

 
We decided that the Plan does not have to waive the copayment for a screening mammogram (codes 77067 and 
77063) provided on January 5, 2022. 
 
You asked the Plan to waive the copayment for a screening mammogram. You say that according to your 
Medicare coverage a screening mammogram is covered in full. 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 40% 
coinsurance for out-of-network screening mammogram.  
 
According to the EOC, a cost share amount applies to a screening mammogram when provided by an out-of-
network provider. You have been asked to pay $51.06, which is 40% coinsurance of the allowed amount for a screening mammogram (code 77067) ($127.65 allowed amount x 40% coinsurance = $51.06). You have also 
been asked to pay $20.96, which is 40% coinsurance of the allowed amount for a screening 3D mammogram 
(code 77063) ($52.40 allowed amount x 40% coinsurance = $20.96). You have been asked to pay a total of 
$72.02 ($51.06 coinsurance + $20.96 coinsurance = $72.02). A screening mammogram falls within the Breast 
Cancer Screening (Mammograms) 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 
screening mammogram (codes 77067 and 77063) provided on January 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the X-ray provided on April 8, 2021 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the X-ray. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because this provider is 
out-of-network with the Plan and the ordering physician was also out-of-network with the Plan. 
 
 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 X-ray provided on April 8, 2021 by an out-of-
network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic procedures, manual therapy services, and 
therapeutic activities provided on November 29, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for therapeutic procedures, manual therapy services, and therapeutic activities. 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 also non-
participating. The Plan also says that they did not authorize any services for 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 therapeutic procedures, manual therapy services, 
and therapeutic activities provided on November 29, 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 copayment for the office visit (99213) provided on 
December 10, 2021. 
 
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 
copay for office visits to specialists at an independence office.  
 
You have been asked to pay a $50 copayment for the specialist office visit provided. 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 office visit (99213) provided on  
December 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital visit provided on January 28, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient hospital visit. You say that these services were medically necessary. 
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 outpatient hospital visit provided on January 28, 
2022 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Rubidium RB-82 DX, and a regadenoson 
injection provided on December 7, 2021. 
 
You asked the Plan to waive the coinsurance for Rubidium RB-82 DX, and a regadenoson injection. You say 
that you do not understand why you have a balance due, and were told that your copayment was $10, which 
you paid. 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 20% 
coinsurance for each Medicare-covered medical supply, and 5% coinsurance for each Medicare Part B 
Prescription Drugs.  
 You have been asked to pay $208.30 in coinsurance, which is 20% of the allowed amount for Rubidium RB-82 
DX ($1,041.50 allowed amount x 20% coinsurance = $208.30). Rubidium RB-82 DX falls within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. You have also been asked 
to pay $11.91 in coinsurance, which is 5% of the allowed amount for a regadenoson injection ($238.20 allowed 
amount x 5% coinsurance = $11.91). A regadenoson 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 Rubidium RB-82 DX, and a 
regadenoson injection provided on December 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy provided on November 16, 2021. 
 
You asked the Plan to pay for infrared therapy. The Plan denied your request. The Plan says infrared therapy is 
considered not reasonable and necessary by Medicare and is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to conclude the use of 
Infrared therapy devices and any related accessories is not reasonable and necessary. 
 
We looked at the file and Medicare rules. Medicare says that there is sufficient evidence to conclude the use of 
Infrared therapy devices and any related accessories is not reasonable and necessary. Therefore, we decided 
that the Plan does not have to pay for infrared therapy provided on November 16, 2021.
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 
January 18, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you refused treatment and left the 
ER. 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.  
 
The record shows you were evaluated at the ER after a motor vehicle accident. 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 January 18, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for subsequent nursing facility care provided on 
January 12, 2022. 
 
You asked the Plan to waive the deductible for the nursing care. You say that you did not have a visit on this 
date. 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 $500 deductible which applies to certain items and services.  
 
The record shows that you were seen at treated for wound care on January 12, 2022. The item or service you 
asked the Plan to waive the deductible for 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 nursing care was received on January 12, 2022. Therefore, we 
decided that the Plan does not have to waive the deductible for subsequent nursing facility care provided on 
January 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit, an office visit, a yearly screening 
for alcohol use, and a depression screening provided on January 19, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for an annual wellness visit, an office visit, a yearly screening for alcohol use, and a 
depression screening. You say that you are appealing with supporting records. The Plan denied your request. 
The Plan says the service performed by the non-participating provider was not authorized by the Plan, and was 
not referred by a participating 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 an annual wellness visit, an office visit, a yearly 
screening for alcohol use, and a depression screening provided on January 19, 2022, 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 the office visit received on February 5, 
2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that you have no idea who the doctor is 
that the Plan references and they are not your PCP. 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 $10 for 
each covered visit or consultation in an outpatient location with your PCP or other primary care provider.  
 
  You have been asked to pay $10 for the office visit. The 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 the office visit received on February 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient admission from January 17, 2022 
to January 24, 2022. 
 
You asked the Plan to waive the copayment for inpatient admission. You say that you had the same service 
back in October and you did not receive a bill. You say that you are asking for a reconsideration of this 
copayment amount. The Plan denied your request. The Plan says you have been charged the correct copayment 
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 $370 a 
day copayment for days 1-5 and a $0 a day copayment for days 6-90 for each inpatient admission per benefit 
period; this includes medical, surgical and rehabilitation services.  
 
 
 You have been asked to pay a $370 copayment for inpatient admission ($370/day x 5 days = $1850). Inpatient 
admission 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 admission from January 17, 2022 to January 24, 2022.
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 
thorax provided on November 8, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you were not aware of the 
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 $250 
copayment per day for diagnostic radiology services that are not ultrasounds.  
 
You have been asked to pay $132.12, which is less than the $250 copayment for the CT scan. 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 thorax provided 
on November 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) rendered by the out-of-network 
(OON) provider on January 12, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization or a referral from your primary care physician. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99203) rendered by the out-of-network (OON) provider on January 12, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the injection provided on January 27, 
2022. 
 
You asked the Plan to waive the coinsurance for the injection. You say that the injection should have been 
included with your office visit copay. 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 Medicare Part B non-chemotherapy prescription drugs.  
 
 
  You have been asked to pay $1.78 (allowed amount=$8.88 x 20%) for the 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 injection provided on January 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine laboratory services provided on November 2, 2021. 
 
You asked the Plan to pay for routine laboratory services. You say that the services at issue were billed 
correctly to the Plan. The Plan denied your request. The Plan says rules for payment for ESRD laboratory 
services have not been met. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab 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 
routine laboratory services provided on November 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PureWick Female External Catheter Urine Collection 
System. 
 
You asked the Plan to pre-approve a PureWick Female External Catheter Urine Collection System. You say 
that the requested PureWick Female External Catheter Urine Collection System is medically necessary. The 
Plan denied your request. The Plan says the requested PureWick Female External Catheter Urine Collection 
System is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 a PureWick Female External Catheter 
Urine Collection System. Our reviewer says that the requested PureWick Female External Catheter Urine 
Collection System is not medically necessary. Our physician reviewer found the enrollee is with unspecified 
urinary incontinence. The records do not give any further details. There is no record of an evaluation of the 
incontinence or prior treatments. The requested PureWick Female External Catheter Urine Collection System is 
not medically reasonable and necessary for the enrollee in this case. There are no peer-reviewed articles 
published in the medical literature specific to the PureWick system, or external urinary collection system using a continuous low-pressure pump. Thus, there is no evidence to show the PureWick system to be an effective 
alternative in managing urinary incontinence. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a PureWick Female External Catheter Urine Collection System have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a PureWick Female External Catheter 
Urine Collection System.