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

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
January 03, 2023. 
 
You asked the Plan to waive the copayment for the ambulance services. 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 $325 
copayment for ambulance services. 
 
You have been asked to pay a $325 copayment for the 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 the ambulance 
services provided on January 03, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from June 1, 2022, to 
June 19, 2022. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that the member is on a limited income 
and the copayment is way too high. 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 $20 copayment per day for days 1 to 20, a $80 copayment per day for days 21 to 44, and $0 
copayment per day for days 45 to 100 for SNF care.  
 The enrollee has been asked to pay a $1,040 copayment for a SNF stay ($20 per day x 8 days = $160) + ($80 
per day x 11 days = $880). This item/service falls within the SNF care 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 copayment for a SNF stay provided from June 1, 2022, to June 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography scan provided 
on September 21, 2022. 
 
You asked the Plan to waive the copayment for the computed tomography scan. You say that the services were 
improperly billed. 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 $135 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $135 copayment for the computed tomography scan. 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 waive the copayment for the computed tomography scan provided on September 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on December 05, 
2022. 
 
You asked the Plan to pay for the domiciliary or rest home visit. You say that the assisted living facility is 
responsible for obtaining authorization. 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 domiciliary or rest 
home visit provided on December 05, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on 
December 26, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you want to request 
that it be categorized as a Post Op event which would be fully covered or at least not chargeable to you. 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 $120 
copayment for emergency care. 
 
You have been asked to pay a $120 copayment for emergency room services. 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 emergency room services 
provided on December 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on November 02, 
2022. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that it is the responsibility of the facility 
to obtain authorization. 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 domiciliary or rest home 
visit provided on November 02, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 provided on July 19, 2022. 
 
You asked the Plan to pay for procedure code 99214. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid 
claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on August 11, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for procedure code 99214 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99214 provided on July 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for infusion services provided from 
November 2, 2022, to November 23, 2022. 
 
You asked the Plan to waive the copayments for the infusion services. You say that the services were ordered 
by your doctor. 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 $450 
copayment for surgery or other services provided at an outpatient hospital.  
 
 
  You have been asked to pay $215.95 for each infusion and $84.48 for each drug injection, which are less than 
the standard $450 copayment. This item/service falls within the surgery or other services provided at an 
outpatient hospital 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 infusion services 
provided from November 2, 2022, to November 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 31, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support 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 an office visit provided 
on August 31, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rest home visit provided on December 12, 2022. 
 
You asked the Plan to pay for rest home visit. You say that you were not able to verify eligibility and obtain 
authorization. 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 rest home visit provided 
on December 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit provided on January 09, 2023. 
 
You asked the Plan to pay for home visit. You say that you are requesting the submitted documentation be 
reviewed. 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 home visit provided on 
January 09, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT colonography. 
 
You asked the Plan to pre-approve a CT colonography. You say that the CT colonoscopy is non-invasive and a 
lower risk. The Plan denied your request. The Plan says a CT colonography is not medically necessary. 
 
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 colonography. Our reviewer says 
that a CT colonography is not medically necessary. Our physician reviewer found that based on the limited 
patient statement provided your request appears to be for a screening CT colonography in lieu of an optical 
colonoscopy. Therefore, the LCD coverage criteria has not been met. 
 
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 colonography have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a CT colonography.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-rays provided on November 07, 2022. 
 
You asked the Plan to pay for x-rays. 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 x-rays provided on 
November 07, 2022.
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 
September 25, 2022, to October 17, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that this seems to be an 
issue relating to a private room charge. 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 $500 copayment for each inpatient hospital admission.  
 
Due to meeting the out-of-pocket maximum during the processing of this claim the enrollee has been asked to 
pay $102.93, which is less than the standard $500 copayment for the inpatient hospital stay. This item/service 
falls within the inpatient hospital care 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 
copayment for the inpatient hospital stay provided from September 25, 2022, to October 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the arthrocentesis and the betamethasone 
acetate injection provided on November 28, 2022. 
 
You asked the Plan to waive the cost share for the arthrocentesis and the injection. You say that you say that 
you never received an injection. 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 surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers. Your contract with the Plan 
also says that there is a $125 copayment after the deductible is met for each outpatient surgery and/or services. 
Your contract with the Plan also says that there is 20% coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay $63.85 towards your deductible for the arthrocentesis. 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 arthrocentesis was received on 
November 28, 2022. 
 
You have also been asked to pay $5.46, which is 20% coinsurance of the allowed amount for the injection 
($27.28 allowed amount X 20% = $5.46). 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. 
Therefore, we decided that the Plan does not have to waive the cost share for the arthrocentesis and the 
betamethasone acetate injection provided on November 28, 2022.
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 
December 16, 2022, to December 21, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you received such poor 
care that you should not have to pay. 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 $295 
copayment per day for days 1-6 of each inpatient hospital stay. Your contract with the Plan also clearly says that you then pay a $0 copayment per day for any additional days of the same stay. 
 
You have been asked to pay a $295 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 charged for the day you 
were discharged. You have been asked to pay a total of $1,475 ($295 copayment per day x 5 days = $1,475). 
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 December 16, 
2022, to December 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided on February 02, 2023. 
 
You asked the Plan to pay for the chiropractic services. 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 the chiropractic services 
provided on February 02, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on November 22, 2022. 
 
You asked the Plan to pay for lab testing. You say that you believe the services are 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 lab testing provided on 
November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit and debridement services provided on 
November 15, 2022. 
 
You asked the Plan to pay for a home visit and debridement services. 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 home visit and 
debridement services provided on November 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network acute inpatient stay provided 
on November 28, 2022, to November 29, 2022. 
 
You asked the Plan to waive the copayment for an in-network acute inpatient stay. You say that you were not 
given a room and were only checked on a few times. You feel you should not have to pay this copayment, on 
top of the ER 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 $300 
copayment for inpatient hospital care. 
 
You have been asked to pay a $300 copayment for an in-network acute inpatient stay. 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 in-network acute inpatient stay provided on November 28, 2022, to November 29, 2022.