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

 
We decided that the Plan does not have to waive the coinsurance for an in-network injection provided on 
March 24, 2023. 
 
You asked the Plan to waive the coinsurance for an in-network injection. You say that they put the injection in 
the wrong place the first time, this was to correct that issue. 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.  
 
The allowed amount of this item is $780.86, resulting in a coinsurance amount of $156.17 ($780.86 x 20% = 
$156.17). You are being asked to pay $142.44 which is less than the 20% coinsurance. You have been asked to pay $142.44 coinsurance for an in-network 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. Therefore, we decided that the Plan does not have to waive the coinsurance for 
an in-network injection provided on March 24, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the hospital services provided on May 17, 
2023. 
 
You asked the Plan to reduce the copayment for the hospital services. You say that you did not have services 
rendered at a hospital. 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 in-network outpatient hospital services. 
 
You have been asked to pay a $200 copayment for the hospital services. This item/service falls within the in-
network outpatient hospital 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 services were rendered at a hospital clinic Therefore, we 
decided that the Plan does not have to reduce the copayment for the hospital services provided on May 17, 
2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the stress test provided on April 12, 2023. 
 
You asked the Plan to waive the copayment for the stress test. You say that the procedure was rendered in an 
office. 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 outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $25 copayment for the stress test. 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. The record shows the provider bills through a hospital. Therefore, 
we decided that the Plan does not have to waive the copayment for the stress test provided on April 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a specialist office visit provided on March 
08, 2023. 
 
You asked the Plan to reduce the copayment for a specialist office visit. You say that you would like the claim 
to be reprocessed at the in-netowrk benefit level. 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 $65 
copayment for out-of-network physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $65 copayment for a specialist office visit. This item/service falls within the out-of-network 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 reduce the copayment for a specialist office visit provided on March 08, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for the osteogenesis stimulator provided on March 25, 
2023. 
 
You asked the Plan to waive the coinsurance for the osteogenesis stimulator. You say that your primary care 
provider said you would only pay around $500 for this service. The Plan denied your request. The Plan says 
that 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 enrollees do not have any coinsurance, copayments, or deductibles for durable 
medical equipment and related supplies.  
 
The Plan says you must pay 20% coinsurance for the osteogenesis stimulator. Based on the Plan contract, 
however, you cannot be asked to pay more than 0% coinsurance for the osteogenesis stimulator. Therefore, we 
decided that the Plan has to waive the coinsurance for the osteogenesis stimulator provided on March 25, 2023.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the dilatation procedure provided on May 
18, 2023. 
 
You asked the Plan to reduce the coinsurance for the dilatation procedure. You say that you were told that you 
would only have to pay a $150 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 20% 
coinsurance for in-network outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay 20% coinsurance for the dilatation procedure. This item/service falls within the in-network 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. The amount you owe is 
$322.59 ($1,612.96 allowed amount x 20% = $322.59). Therefore, we decided that the Plan does not have to 
reduce the coinsurance for the dilatation procedure provided on May 18, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 14, 2022, to 
February 5, 2022. 
 You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the NOA was not received timely. As 
such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 14, 2022. The NOA was not received by the Plan until June 10, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
provided from January 14, 2022, to February 5, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for take-home supply of methadone provided on April 17, 2023. 
 
You asked the Plan to pay for take-home supply of methadone. You say that the services 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 take-home supply of 
methadone provided on April 17, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on November 
17, 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 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the drug injection provided on June 01, 
2023. 
 
You asked the Plan to waive the coinsurance for the drug injection. You say that you were told you only have 
to pay the $25 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 20% 
coinsurance for Medicare Part B drugs. 
 
You have been asked to pay 20% coinsurance for the drug injection. This item/service falls within the 
Medicare Part B 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 you owe for the drug injection is $252.72 ($1,263.60 allowed amount x 20% 
coinsurance = $252.72). Therefore, we decided that the Plan does not have to waive the coinsurance for the 
drug injection provided on June 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on April 24, 
2023. 
 
You asked the Plan to pay for an office visit and related services. You say that the services 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 an office visit and 
related services provided on April 24, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the breast ultrasound provided on February 
01, 2023. 
 
You asked the Plan to waive the copayment for the breast ultrasound. You say that you always pay $0 for 
preventative mammograms. 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 $50 
copayment for in-network outpatient radiology services provided in a specialists office. 
 
You have been asked to pay a $50 copayment for the breast ultrasound. This item/service falls within the in-
network outpatient radiology services provided in a specialists office 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 records show a breast ultrasound 
was provided, not a screening mammogram, and the copayment was correctly applied. Therefore, we decided 
that the Plan does not have to waive the copayment for the breast ultrasound provided on February 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit for the evaluation and management provided on 
April 20, 2023. 
 
You asked the Plan to pay for a home visit for the evaluation and management. 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 a home visit for the 
evaluation and management provided on April 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit for the evaluation and management provided on 
April 18, 2023. 
 
You asked the Plan to pay for a home visit for the evaluation and management. 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 a home visit for the 
evaluation and management provided on April 18, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on March 28, 2023. 
 
You asked the Plan to pay for an x-ray. You say that you are requesting reconsideration of the denied claim. 
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 x-ray provided on 
March 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for chiropractic services provided on March 
02, 2023, to March 06, 2023. 
 
You asked the Plan to waive the copayment for chiropractic services. You say that you do not agree with the 
amount you were 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 $25 
copayment for chiropractic services. 
 
You have been asked to pay a $25 copayment for chiropractic services. This item/service falls within the 
chiropractic 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 total you owe is $50 ($25 COST SHARE x 2 VISITS = $50). Therefore, we decided that the 
Plan does not have to waive the copayment for chiropractic services provided on March 02, 2023, to March 06, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic visit provided on March 21, 2023. 
 
You asked the Plan to pay for a chiropractic visit. 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 chiropractic visit 
provided on March 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on April 06, 2023. 
 
You asked the Plan to pay for a home visit. You say that the provider was not 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 a home visit provided on 
April 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ESRD related services provided on April 1, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the ESRD related services. You say that you are requesting reconsideration of 
the denied claim. The Plan denied your request. The Plan says the service was not authorized. 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 ESRD related services provided on April 1, 
2023, by OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on March 09, 2023. 
 
You asked the Plan to pay for the anesthesia services. You say that anesthesia should be paid at the in-network 
rate. 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 anesthesia services 
provided on March 09, 2023.