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

 
We decided that the Plan does not have to waive the cost for an in-network magnetic resonance imaging (MRI) 
of the head provided from March 7, 2022, to March 30, 2022. 
 
You asked the Plan to waive the cost for an in-network MRI of the head . You say that you had already met the 
deductible and out of pocket maximum at the time of this service. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $115 copayment for other outpatient diagnostic tests - radiological diagnostic services, not 
including x-rays, and a 20% coinsurance for Medicare Part B drugs.  You have a $115 copayment for an MRI + the allowable amount of $4.95 for Medicare Part B drugs = $119.95 
total cost. 
 
The enrollee has been asked to pay a $119.95 total cost for an in-network MRI of the head. This item/service 
falls within the other outpatient diagnostic tests - radiological diagnostic services, not including x-rays and 
Medicare Part B drug benefit category. This means that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the cost for an in-
network magnetic resonance imaging (MRI) of the head provided from March 7, 2022, to March 30, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the facility charge, and the provider 
services applied during the colonoscopy provided on December 22, 2022. 
 
You asked the Plan to reduce the cost share for the facility charge and the provider services. You say that you 
would like the cost share for the procedure to be applied to the 2023 annual deductible. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1,500 deductible which applies to the facility and the provider 
services. Your contract with the Plan also says that there is a $395 copayment, after your plan deductible for 
each Medicare-covered outpatient surgery at an outpatient hospital facility. 
 You have been asked to pay $609.53 towards your deductible for the provider services received during the 
colonoscopy. You have also been asked to pay $855.82, which satisfies the remainder of your deductible for 
the facility charge applied during the colonoscopy. The Plan has followed Medicare rules by clearly disclosing 
in the contract that there is a $1,500 deductible which applies to outpatient surgery, including services provided 
at hospital outpatient facilities. This cost sharing is a contractual obligation that had not been met at the time of 
the facility charge and the provider services were provided on December 22, 2022. 
 
You have also been asked to pay a $395 copayment for the facility charge applied during the colonoscopy. 
These items/services fall within the outpatient surgery, including services provided at hospital outpatient 
facilities 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 cost share for the facility charge, and the 
provider services applied during the colonoscopy provided on December 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue additional reimbursement for the gym membership (S9970) 
purchased on January 1, 2022. 
 
You asked the Plan to issue additional reimbursement 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 you have 
exhausted the maximum allowable benefit for this service.  
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
  
 
 
The Plans rules for coverage of gym benefits have not been met because you have exhausted the allowable 
benefit for this service. Specifically, the plan reimburses you up to $150 per calendar year towards your cost 
for membership in a qualified health club or fitness facility. The Plan previously issued reimbursement to you 
in the amount of $150 on February 17, 2023 for this membership. Therefore, you have exhausted the allowable 
benefit for this service. Therefore, we decided that the Plan does not have to issue additional reimbursement for 
the gym membership (S9970) purchased on January 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services provided on January 16, 2023. 
 
You asked the Plan to waive the copayment for lab services. You say that you were not told that there would be 
a copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 
copayment for in-network Medicare-covered lab tests. 
 
You have been asked to pay a $15 copayment for lab services. This item/service falls within the in-network 
Medicare-covered lab tests 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 lab services 
provided on January 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the specialist visit, and the earwax 
removal provided on January 31, 2023. 
 
You asked the Plan to waive the cost sharing for the specialist visit and the earwax removal. You say that you 
do not feel that you should be paying for services that you did not receive. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible which applies to the earwax removal, and that you 
must pay a $35 copayment for each in-person specialist visit. 
 
 You have been asked to pay a $35 copayment for the specialist visit. This item/service falls within the 
physician/practitioner services, including doctor's office visits benefit category. You have also been asked to 
pay a $46.21 deductible for the earwax removal. This item/service falls within the outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. 
This cost sharing is a contractual obligation that had not been met at the time the specialist visit, and the earwax 
removal was provided on January 31, 2023. Therefore, we decided that the Plan does not have to waive the cost 
sharing for the specialist visit, and the earwax removal provided on January 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on September 21, 2022, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that the services rendered were medically necessary. The 
Plan denied your request. The Plan says enrollees must receive their care from a network 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 item/service 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 this item/service. Therefore, 
we decided that the Plan does not have to pay for the office visit provided on September 21, 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 November 15, 2022. 
 
You asked the Plan to pay for an office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on November 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network office visit provided on 
January 26, 2023. 
 
You asked the Plan to waive the copayment for an in-network office visit. You say that you have memory 
issues and feel this should be waived. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $10 copayment for an in-network office visit. This item/service 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 an in-network office visit provided on January 26, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a biopsy of lymph nodes, surgical preparation, and an 
adjacent tissue transfer procedure provided on November 11, 2022. 
 
You asked the Plan to pay for a biopsy of lymph nodes, surgical preparation, and an adjacent tissue transfer 
procedure. You say that these services were medically necessary. The Plan denied your request. The Plan says 
that unauthorized, out-of-network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a biopsy of lymph 
nodes, surgical preparation, and an adjacent tissue transfer procedure provided on November 11, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
December 27, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you would like the 
Plan to fully cover this service. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for ambulance services. 
 
You have been asked to pay a $200 copayment for the ambulance transportation. This item/service falls within 
the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
ambulance transportation provided on December 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on November 04, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that we depend on the referring provider or facility to 
verify plan information. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory testing 
provided on November 04, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DEXA provided on December 22, 2022. 
 
You asked the Plan to pay for DEXA. You say that you are requesting reconsideration for the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for DEXA provided on 
December 22, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
November 25, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the enrollee did not 
received services from AMR. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for ambulance services.  
You have been asked to pay a $250 copayment for the ambulance transportation. This item/service falls within 
the ambulance services benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. The record shows you have received ambulance services provided by AMR on November 
25, 2022. However, since the allowed amount is less than the standard copayment, you only owe $175. 
Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transportation 
provided on November 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraspinal chiropractic manipulative treatment (98943) 
and the electrical stimulation (G0283) provided on November 25, 2022 and December 4, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the extraspinal chiropractic manipulative treatment (98943) and the 
electrical stimulation (G0283) provided on November 25, 2022 and December 4, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the abdominal ultrasound provided on 
December 20, 2022. 
 
You asked the Plan to waive the copayment for the abdominal ultrasound. You say that the Plan paid $0 for this 
service. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $165 
copayment for in-network outpatient diagnostic radiology, including ultrasounds. 
 
You have been asked to pay a $165 copayment for the abdominal ultrasound. This item/service falls within the 
in-network outpatient diagnostic radiology, including ultrasounds benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. However, since the allowed amount is less than the 
standard copayment, you only owe $131.72. Therefore, we decided that the Plan does not have to waive the 
copayment for the abdominal ultrasound provided on December 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the retina imaging services provided on 
December 22, 2022. 
 
You asked the Plan to waive the copayment for the retina imaging services. You say that you already paid for 
the office visit and should not have to pay for this as well. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for in-network diagnostic tests, including x-rays. 
 
You have been asked to pay a $35 copayment for the retina imaging services. This item/service falls within the 
in-network diagnostic tests, 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. The record shows that both an office visit and retina imaging services were 
provided, and both copayment were correctly applied. Therefore, we decided that the Plan does not have to 
waive the copayment for the retina imaging services provided on December 22, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on November 
20, 2022, to November 21, 2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for ambulance services. 
 
You have been asked to pay a $250 copayment for ambulance services. This item/service falls within the 
ambulance services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services 
provided on November 20, 2022, to November 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wound debridement procedure provided on February 13, 
2023. 
 
You asked the Plan to pay for a wound debridement procedure. You say that this was medically necessary and 
should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a wound debridement 
procedure provided on February 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) and the vertebral axial 
decompression, per session (S9090) provided from September 22, 2022, through November 30, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not a covered benefit by Medicare or the Plan. Therefore, we 
decided that the Plan does not have to pay for the office visit (99203) and the vertebral axial decompression, 
per session (S9090) provided from September 22, 2022, through November 30, 2022.