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

 
We decided that the Plan does not have to waive the copayment for an IRF admission provided from May 17, 
2023, to May 25, 2023. 
 
You asked the Plan to waive the copayment for an IRF admission. You say that you disagree with the 
copayment applied. 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 $325 
copayment per day for days 1 to 6 and $0 copayment for additional days for inpatient hospital care. 
 
 
  You have been asked to pay a $1,950 copayment for an IRF admission ($325 per day x 6 days = $1,950). This 
item/service 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 an IRF admission provided from May 17, 2023, to May 25, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed 
tomography (CT) chest calcium score test (75571). 
 
You asked the Plan to pre-approve a CT chest calcium score test. 
You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
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 CT chest calcium 
score test. Our reviewer says that the requested items/services are 
not considered medically reasonable and necessary in this case. 
Our physician reviewer found the review indicates that the medical 
information received did not include information necessary to 
meet the above rules. The enrollee has hypertension and no 
reported history or suspicion of coronary artery disease. The 
review has determined that the items/services at issue in this case 
are not medically reasonable or necessary. 
 
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 CT chest calcium score test have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a 
computed tomography (CT) chest calcium score test (75571).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - periapical first radiographic image (D0220) 
provided on May 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that the Plan needs to honor their representation on 
coverage. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 17, 2023. 
Therefore, we decided that the Plan does not have to pay for an intraoral - periapical first radiographic image 
(D0220) provided on May 3, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on May 01, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that your provider 
requested the scan as a medical necessity. 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 $150 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $150 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic 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. The total copayment you owe is $147.74, which is less than the standard 
copayment for a CT scan. Therefore, we decided that the Plan does not have to waive the copayment for a 
computed tomography (CT) scan provided on May 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the physical therapy services provided on 
July 31, 2023, to August 11, 2023. 
 
You asked the Plan to waive the deductible for the physical therapy services. You say that you were told that 
these services would be fully covered. 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 outpatient rehabilitation services. 
Your contract with the Plan also clearly says that you must pay a pay a $0 copayment after the deductible is 
met for each therapy visit. 
 
 You have been asked to pay $114.44 towards your $750 deductible for the physical therapy visit provided on 
July 31, 2023. You have also been asked to pay $84.39 towards your $750 deductible for each physical therapy 
visit provided on August 2, 2023, August 7, 2023, and August 11, 2023. The items or services you asked the 
Plan to waive the deductible for fall within the outpatient rehabilitation services benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to 
outpatient rehabilitation services. This cost sharing is a contractual obligation that had not been met at the time 
the physical therapy services was received on July 31, 2023, to August 11, 2023. Therefore, we decided that the 
Plan does not have to waive the deductible for the physical therapy services provided on July 31, 2023, to 
August 11, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the subsequent hospital inpatient or observation care, per day, for the 
evaluation and management of a patient (99232) provided on February 9, 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 that this service is not payable as the claim 
was submitted untimely.  
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a corrected claim was submitted on January 3, 2023. Therefore, the claim was submitted 
timely within one calendar year of the date of service and the determination issued by the Plan. Therefore, we 
decided that the Plan has to pay for the subsequent hospital inpatient or observation care, per day, for the 
evaluation and management of a patient (99232) provided on February 9, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
May 29, 2023, to June 3, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you cannot afford this 
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 $275 
copayment per day for days 1-5 and a $0 copayment per day for any additional days of each inpatient hospital 
stay.  
 You have been asked to pay a $275 copayment per day for days 1-5 of the inpatient hospital stay. This 
item/service falls within the inpatient hospital care benefit category. You have not been asked to pay after day 
five or for the day you were discharged. You have been asked to pay a total of $1,375 ($275 copayment per day 
x 5 days = $1,375). This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital stay 
provided from May 29, 2023, to June 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vertical bitewings (D0277) provided on January 31, 2023. 
 
You asked the Plan to pay for the dental services. You say that there was no in-network dentist that could see 
you. The Plan denied your request. The Plan says the dental services were received from an out-of-network 
provider and are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for vertical bitewings (D0277) provided on January 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hearing exam provided on May 25, 
2023. 
 
You asked the Plan to waive the copayment for the hearing exam. You say that the provider did not disclose 
this copayment amount before the hearing test. 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 $25 
copayment for hearing services. 
 
You have been asked to pay a $25 copayment for the hearing exam. This item/service falls within the hearing 
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 hearing exam provided 
on May 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on May 03, 2023. 
 
You asked the Plan to waive the coinsurance for an injection. You say that the injections were administered in 
the office and you never had to pay for them before. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for an injection. This item/service 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. The total coinsurance you owe is $215.81, which is 20% of the allowed amount for a Medicare Part 
B drug injection ($1,079.04 allowed x 20% = $215.81). Therefore, we decided that the Plan does not have to 
waive the coinsurance for an injection provided on May 03, 2023.
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 
February 21, 2023, to February 22, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you feel the 
copayment should be waived because you stayed over 24 hours in the emergency room. 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 $100 
copayment for emergency care. 
 
You have been asked to pay a $100 copayment for an emergency room (ER) visit. This item/service 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 February 21, 2023, to February 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a hearing test and and a tympanometry test 
provided on June 06, 2023. 
 
You asked the Plan to waive the copayment for a hearing test and and a tympanometry test. You say that this 
was an annual routine test. 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 $45 
copayment for hearing services. 
 
You have been asked to pay a $45 copayment for a hearing test and and a tympanometry test. This item/service 
falls within the hearing 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. However, since the allowed amount is less than the standard copayment, you 
only owe $36.57. Therefore, we decided that the Plan does not have to waive the copayment for a hearing test 
and and a tympanometry test provided on June 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on June 
27, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that this appointment was 
rescheduled, and you feel the Plan should waive this copayment since you had to take the day off of work. 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 specialist physician/practitioner services. 
 
You have been asked to pay a $35 copayment for the specialist office visit. This item/service falls within the 
specialist physician/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 copayment 
for the specialist office visit provided on June 27, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and 
pelvis. 
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan of the abdomen and pelvis. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
recommendation for a follow-up magnetic resonance imaging (MRI) of the abdomen and pelvis based on the 
CT report of May 16, 2023, is more appropriate than the requested CT of the abdomen and pelvis. 
 
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 CT scan of the abdomen and pelvis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for an out-of-network chest x-ray provided on May 
26, 2023. 
 
You asked the Plan to waive the cost for an out-of-network chest x-ray. You say that you thought this would be 
a temporary arrangement, but it has become permanent. 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 $2500 
out of pocket maximum for convenience care.  
 
You have been asked to pay $60 towards this $2500 out of pocket maximum for an out-of-network chest x-ray. 
This item/service falls within the convenience 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 cost for an out-of-network chest x-ray provided on May 26, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a magnetic resonance imaging provided on 
July 20, 2023. 
 
You asked the Plan to reduce the copayment for a magnetic resonance imaging. You say that you should not be 
charged for the entire procedure as the test could not to be completed. 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 $220 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $220 copayment for a magnetic resonance imaging. This item/service 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 reduce the copayment for a magnetic resonance imaging provided on July 20, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for an ER visit and self-administered drugs provided 
on June 20, 2023. 
 
You asked the Plan to waive the cost for an ER visit and self-administered drugs. You say that you were 
concerned your leg was infected and had to go to the ER. The Plan denied your request. The Plan says the ER 
cost share was charged correctly and the self-administered drugs are not covered as a medical benefit under the 
Plan. 
 
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 $65 
copayment for emergency care.  
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. 
 
You have been asked to pay $68 for an ER visit and self-administered drugs. This total includes a $65 
copayment for an ER visit and $3 for the self-administered drugs. This item/service 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 cost for an ER visit and self-administered drugs 
provided on June 20, 2023.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on May 30, 2023. 
 
You asked the Plan to pay for the drug testing. You say that you have submitted documentation showing the 
medical necessity of 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 the drug testing 
provided on May 30, 2023.