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

 
We decided that the Plan does not have to waive the copayment for a computerized tomography (CT) Scan on 
December 27, 2021. 
 
You asked the Plan to waive the copayment for a computerized tomography (CT) Scan. You say that you feel 
that you should not owe it. The Plan denied your request. The Plan says the cost share applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment for a computerized tomography (CT) Scan.  
 
You have been asked to pay a $225 copayment for a computerized tomography (CT) Scan. A computerized 
tomography (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 computerized tomography (CT) Scan on 
December 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (82656, 83520, 83631, 87150) provided 
on January 28, 2021. 
 
You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan 
denied your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for laboratory services (82656, 83520, 83631, 87150) provided on January 28, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for Practitioner Services on September 21, 
2021 to November 15, 2021. 
 
You asked the Plan to waive the copayments for Practitioner Services. You say that you would like to appeal 
the cost share. The Plan denied your request. The Plan says the member's deductible hadn't been met until after 
these services were received. 
 
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 
$2,619.92 cost share for Practitioner Services.  
 
You have been asked to pay $2,619.92 cost share for Practitioner Services. Practitioner Services falls within the 
Practitioner 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 Practitioner 
Services on September 21, 2021 to November 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 24, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the physician sent the specimens to your 
laboratory to process, and you would like reconsideration on paying the claim. 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 January 24, 
2022, 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 December 15, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that your primary care physician's office was closed so 
you went to the clinic across the street. The Plan denied your request. The Plan says the rendering provider is 
an OON provider and there was no approved authorization. 
 
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. There was no documentation provided to show if the service rendered would fall under 
the emergency or urgently needed care exception. 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 
December 15, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on June 2, 2021. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says as a 
managed care plan, Medicare rules allow us to restrict members to our network and deny out of network care 
except in rare circumstances. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on June 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic imaging of the retina provided 
on February 4, 2022. 
 
You asked the Plan to waive the copayment for diagnostic imaging of the retina. You say that there should be a 
$0 copayment for diabetic retinopathy screening. 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 $40 
copayment for outpatient diagnostic tests performed by a specialty physician.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
the allowed amount of $36.98, which is less than the $40 copayment for diagnostic imaging of the retina. Diagnostic imaging of the retina 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 diagnostic imaging of the 
retina provided on February 4, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the behavioral health services provided on 
January 21, 2022, and February 4, 2022. 
 
You asked the Plan to waive the copayment for the behavioral health services. You say that your primary care 
physician referred you to the specialist and you would of never went to the provider if you knew it would not 
be covered. The Plan denied your request. The Plan says the enrollee was referred by a participating provider to 
an out-of-network provider. Therefore, the claims were reprocessed as in-network benefits and the proper 
copayment of $40 was applied for each date of service. 
  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 each Medicare-covered individual session for outpatient mental health services provided by a 
psychiatrist or a by a mental health professional.  
 
You have been asked to pay a $40 copayment for the behavioral health services. The behavioral health services 
falls within the Outpatient mental health 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 behavioral health services provided on January 21, 2022, and February 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on December 21, 2021. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says as a 
managed care plan, Medicare rules allow us to restrict members to our network and deny out of network care 
except in rare circumstances. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on December 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $90 copayment for emergency room services provided on 
September 9, 2021. 
 
You asked the Plan to waive the $90 copayment for emergency room services provided on September 9, 2021. 
You say that you went to the emergency room on September 9, 2021 and should not be responsible for the $90 
copayment because you were admitted to the hospital. The Plan denied your request. The Plan says you pay a 
$90 copayment for emergency room services. 
 
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 emergency care. Your contract with the Plan also says you do not pay the emergency room visit 
cost share if you are admitted to the hospital within 24 hours for the same condition. 
 
 
 You have been asked to pay a $90 copayment for emergency room services. Emergency room services fall 
within the emergency care benefit category. Please note, the documentation does not support that you were 
formally admitted as a hospital inpatient. 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 $90 copayment for 
emergency room services provided on September 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for ostomy skin barrier supplies provided 
from February 9, 2022, to February 18, 2022. 
 
You asked the Plan to waive the coinsurance for the ostomy supplies. You say that your copayment was always 
$1 per year for all the supplies. The Plan denied your request. The Plan says the correct coinsurance 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 20% 
coinsurance for medical supplies, such as ostomy supplies.  
 
You have been asked to pay $1.53 for each of the 10 dates of service, which is 20% of the allowed amount for 
the ostomy supplies ($7.64 allowed amount x 20% coinsurance = $1.53). The total for all supplies is $15.30. The ostomy supplies fall within the Prosthetic Devices 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 ostomy skin barrier supplies provided from February 9, 2022, to 
February 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on January 31, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the specialist office visit. You say that you were told to get an appointment with 
your cardiologist, but you were never informed you needed a referral or they had to be in-network. The Plan 
denied your request. The Plan says the rendering provider is an OON provider and there was no approved 
authorization. It was also confirmed with the enrollee's primary care provider that there was no referral or 
authorization to see the OON cardiologist. 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 a specialist office visit provided on January 31, 
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 outpatient hospital observation care 
provided from December 16, 2021, to December 17, 2021. 
 
You asked the Plan to waive the copayment for the observation care. You say that you were admitted and 
should not have a 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 $100 
copayment for each observation stay.  
 
The file shows no evidence of a written inpatient order from the doctor, and you were only kept under 
observation status. Therefore, you have been asked to pay a $100 copayment for the observation care. The observation care falls within the Outpatient Hospital Observation 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 outpatient hospital observation care provided from December 16, 2021, to 
December 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
March 22, 2021, to March 29, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you received minimal treatment 
and should not be held liable for 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 $295 per 
day for days 1-6 and $0 per day after day 6 for each inpatient admission.  
 
The file shows that you were in the hospital from March 22, 2021, to March 29, 2021. Therefore, you have 
been asked to pay $295 per day for the first 6 days of inpatient care. The total for your stay is $1,770 ($295 copayment x 6 days = $1,770). The inpatient care 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 care provided from March 22, 2021, to 
March 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient hospital surgery provided on 
June 16, 2021. 
 
You asked the Plan to waive the coinsurance for outpatient hospital surgery. You say that you would like the 
Plan to cover the bill. The Plan denied your request. The Plan says the coinsurance amount charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare-covered outpatient surgery services at an outpatient hospital facility.  
 
 
 
 
 
 You have been asked to pay $1,035.10, which is 20% coinsurance of the allowed amount ($5,175.48) for 
outpatient hospital surgery. Outpatient hospital surgery 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 coinsurance for outpatient hospital surgery provided on June 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on February 
10, 2022. 
 
You asked the Plan to waive the copayment for laboratory services. You say that this was routine lab work in 
preparation for your yearly physical. 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 $10 
copayment for in-network laboratory services.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$10 copayment for laboratory services. Laboratory services fall 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 
laboratory services provided on February 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) provided on 
March 4, 2022. 
 
You asked the Plan to waive the copayment for the EKG. You say that you were billed for an inpatient stay 
instead of a specialist visit. 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 $105 
copayment for diagnostic procedures and tests, such as EKG's, provided in an outpatient hospital setting.  
 
You have been asked to pay $52.66, which is less than the $105 copayment for the EKG. There is no evidence in the file showing inpatient hospital charges. The EKG falls within the Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
an electrocardiogram (EKG) provided on March 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the specialist office visit provided on 
January 25, 2022. 
 
You asked the Plan to waive the deductible for the specialist office visit. You say that the office visit was a 
follow-up visit after your surgery and should be covered. The Plan denied your request. The Plan says the 
deductible was applied correctly. At the time the claim processed, you had not met any of your $100 deductible 
so the entire deductible amount of $90.62 was 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 clearly says that there is a $100 deductible that applies to specialist office visits. 
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
Physician/Practitioner Services, Including Doctors Office Visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $100 combined in-network and out-of-network deductible that 
applies to specialist office visits. This cost sharing is a contractual obligation that had not been met at the time 
the office visit was received on January 25, 2022. Therefore, we decided that the Plan does not have to waive 
the deductible for the specialist office visit provided on January 25, 2022.