Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
February 3, 2021, to February 12, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you should not be charged since 
the stay was related to COVID-19. 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 $465 per 
day for days 1-4 and $0 per day for additional days for each inpatient stay.  
 
The file shows that you were in the hospital from February 3, 2021, to February 12, 2021. Therefore, you have 
been asked to pay $465 per day for the first 4 days of inpatient care. The total for your stay is $1,860 ($465 copayment x 4 days = $1,860). Please note that the Plan indicated COVID-19 cost share waivers ended in 
September 2020. 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 February 3, 2021, to February 
12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a botulinum injection provided on October 
12, 2021. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you had this injection procedure in 
the past and did not have a charge for it. You also say that you have not changed insurance plans since then. 
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 20% 
coinsurance for Part B drugs.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
$121.80, which is 20% coinsurance of the allowed amount for an injection ($609 allowed amount x 20% 
coinsurance = $121.80). An 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 a botulinum injection provided on October 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic eye exam provided on 
December 17, 2021. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you should not be charged for your 
annual exam. 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 exams to diagnose and treat diseases of the eye. This may be in addition to a routine eye exam.  
 
The file shows that you were not charged for the routine exam portion, but the copayment does apply to the additional diagnostic exam that was provided. Therefore, you have been asked to pay a $40 copayment for the 
eye exam. The eye exam falls within the Vision 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 a diagnostic eye exam provided on December 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician visit provided on August 2, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the physician visit. You say that it was medically necessary to treat the enrollee 
and would like the claim to be processed for payment. The Plan denied your request. The Plan says the 
rendering provider is an out-of-network provider and there was no referral from an in-network provider or an 
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 physician visit provided on August 2, 2021, by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for reconstruction surgery provided on 
November 17, 2021. 
 
You asked the Plan to reduce the copayment for reconstruction surgery. You say that you were told by the 
insurance company and the hospital your copayment was $125. 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 for outpatient surgery at an outpatient surgery.  
 
You have been asked to pay a $250 copayment for reconstruction surgery. Reconstruction surgery falls within 
the Outpatient Surgery and Other Medical 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 reduce the copayment for reconstruction 
surgery provided on November 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telehealth visit on January 19, 2022. 
 
You asked the Plan to waive the copayment for telehealth visit. You say that you were billed twice for the tele-
visit and for hospital services. You say that you should not have to pay twice for any doctor visit. The Plan 
denied your request. The Plan says the copayment 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 
copayment for each Medicare-covered telehealth service done by specialist.  
 
You have been asked to pay $20 copayment for telehealth visit. The telehealth visit falls within the 
Physician/Practitioner services, including doctor's office visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the Telehealth visit on January 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a back injection procedure performed on 
November 26, 2021. 
 
You asked the Plan to reduce the copayment for the injection. You say that you were informed that your 
copayment would only be $45 for the 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 $350 per 
day for outpatient procedures and services.  
 
You have been asked to pay $350 copayment for the injection. Please note that the office visit copayment of 
$45 would apply as an additional charge, however the file shows that this portion was not billed. The injection is considered a surgical procedure and 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 reduce the copayment for a back injection procedure performed on November 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on September 22, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office 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 the office visit provided on September 22, 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 podiatry specialist office visits provided 
on August 5, 2021, and September 30, 2021, and a foot x-ray provided on September 30, 2021. 
 
You asked the Plan to waive the copayments for a specialist office visit and an x-ray. You say that due to 
complications from foot surgery, additional post-op office visits are necessary. You also say that the first 
appointment after the 90-day approved duration of treatment was August 5, 2021. The Plan denied your 
request. The Plan says you have been charged the correct cost sharing amount. 
 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for a specialist office visit. The Plan contract also says that enrollees must pay a $15 copayment for 
an x-ray. 
 
The record shows the services were rendered after the 90-day global surgery period, and you have a cost 
sharing amount. You have been asked to pay a $35 copayment for each specialist office visit on August 5, 
2021, and September 30, 2021. A specialist office visit falls within the Physician/Practitioner Services, 
Including Doctors Office Visits benefit category. You have also been asked to pay a $15 copayment for an x-
ray on September 30, 2021. An x-ray 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 podiatry specialist office 
visits provided on August 5, 2021, and September 30, 2021, and a foot x-ray provided on September 30, 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 
November 4, 2021. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you were transported to the hospital 
from your doctors office after a leg vein procedure. You say that you should not have to pay the copayment 
and the insurance should pay for everything. 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 $110 
copayment for an emergency room visit.  
 
 The medical record shows you received treatment at the emergency room on November 4, 2021. You have 
been asked to pay a $110 copayment for an ER visit. An 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 
November 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you do not think you 
should pay the cost-sharing because the services were unexpected. The Plan denied your request. The Plan says 
you were charged this cost-sharing 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 for each ambulance trip. You had one (1) ambulance trip. The Plan charged you $350 for these 
services. 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.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an inpatient hospital stay provided from December 
15, 2021, to December 16, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were charged a 
$200 copayment. You also say that you were not admitted as an overnight patient. The Plan denied your 
request. The Plan says that you have been charged the correct cost sharing amount. 
 
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 provide medical records to show if you were admitted as an 
inpatient. Without the medical records we are unable to determine if the cost share applied is correct. 
Therefore, we decided that the Plan has to waive the copayment for an inpatient hospital stay provided from 
December 15, 2021, to December 16, 2021.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a breast ultrasound provided on November 
15, 2021, and a breast biopsy provided on November 30, 2021. 
 
You asked the Plan to waive the cost share for an ultrasound and a biopsy. You say that you thought these 
services were covered. You also say you pay $235 a month for your premium and do not utilize it. 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 20% 
coinsurance up to $75 per day for diagnostic radiology services, including ultrasounds. The Plan contract also 
says that enrollees must pay a $75 copayment for other outpatient procedures and services, including a biopsy. 
 
You have been asked to pay $18.77, which is 20% coinsurance of the allowed amount for an ultrasound on 
November 15, 2021 ($93.87 allowed amount x 20% coinsurance = $18.77). An ultrasound falls within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category.  
 
You have also been asked to pay a $75 copayment for a biopsy on November 30, 2021. You have been asked to 
pay a total of 93.77 ($18.77 coinsurance + $75 copayment = $93.77). A biopsy 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 cost share for a breast ultrasound provided on November 15, 
2021, and a breast biopsy provided on November 30, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for recertification for Medicare covered home health service by 
an allowed physician provided on November 9, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for recertification for Medicare covered home health service by an allowed 
physician. You say that authorization was not obtained prior to seeing this patient since it is the nursing 
facility's responsibility to get authorizations for their patients. The Plan denied your request. The Plan says this 
provider is out-of-network with the Plan, and authorization was not obtained prior to the services being 
rendered. 
 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 recertification for Medicare covered home health 
service by an allowed physician provided on November 9, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cataract surgery provided on December 10, 
2021. 
 
You asked the Plan to waive the copayment for cataract surgery. You say that the service was necessary due to 
complications following your previous surgery. You feel that the copayment should be waived. The Plan 
denied your request. The Plan says the copayment applied was 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 $350 
copayment per day for other outpatient procedures and services, including, but not limited to, diagnostic and 
therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical 
center.   
You have been asked to pay a $350 copayment for cataract surgery. Cataract 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 copayment for cataract surgery provided on December 10, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for ultrasound provided on December 06, 
2021. 
 
You asked the Plan to waive the coinsurance for ultrasound. You say that the copayment for the ultrasound 
should be included in the outpatient surgery you had. 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 20% 
coinsurance up to $75 per day for Medicare-covered diagnostic radiology services.  
  You have been asked to pay $25.29, which is 20% of the allowed amount for the ultrasound. The allowed 
amount is $126.45 (20% x $126.45 = $25.29). The ultrasound 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 coinsurance for 
ultrasound provided on December 06, 2021.