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

 
We decided that the Plan does not have to waive the copayment for an in-network cataract procedure provided 
on March 02, 2023. 
 
You asked the Plan to waive the copayment for an in-network cataract procedure. You say that you cannot 
afford this copayment as you are on a fixed income. 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 Medicare covered outpatient hospital facility visit. 
 
You have been asked to pay a $325 copayment for an in-network cataract procedure. This item/service falls 
within the Medicare covered outpatient hospital facility visit 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 cataract procedure provided on March 02, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cataract removal procedure provided on 
November 2, 2021, and November 16, 2021, and the inpatient hospital stay provided from April 22, 2022, to 
April 29, 2022. 
 
You asked the Plan to waive the copayment for the cataract removal procedures, and the inpatient hospital stay. 
You say that you do not owe anything for these services. 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 each covered surgery or observation room service in an outpatient hospital, and a $299 
copayment per day, per admission, days 1-6, for covered hospital stays. 
 
You have been asked to pay a $650 copayment for the cataract removal procedures ($325 x 2 procedures = 
$650). These items/services fall within the outpatient surgery, including services provided at hospital outpatient 
facilities and ambulatory surgical centers benefit category. You have also been asked to pay a $1794 
copayment for the inpatient hospital stay ($299 x 6 days = $1794). 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 the cataract removal 
procedure provided on November 2, 2021, and November 16, 2021, and the inpatient hospital stay provided 
from April 22, 2022, to April 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 09, 2022. 
 
You asked the Plan to pay for an office visit. You say that prior authorization is not needed for this service. 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 09, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient mental health on May 23, 2022, 
to August 15, 2022.  
 
You asked the Plan to waive the copayment for outpatient mental health. You say that you shouldn't be billed a 
$20 copayment for an x-ray because it's part of the office visit. 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 each individual or group therapy visit for Medicare-covered outpatient mental health services. 
Covered services include mental health services provided by a state-licensed psychiatrist or doctor, clinical 
psychologist, clinical social worker, clinical nurse specialist, nurse practitioner, physician assistant, or other 
Medicare-qualified mental health care professional as allowed under applicable state laws. There were two 
visits. 2 x $25 = $50. Therefore, results in the total cost shairng amount of $50.  
 
You have been asked to pay a $25 copayment for each outpatient mental health. This item/service falls within 
the outpatient mental health 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 
outpatient mental health on May 23, 2022, to August 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the urgent care visit, primary care office 
visit, and x-ray provided from March 17, 2022, to April 12, 2022. 
 
You asked the Plan to waive the copayments for the urgent care visit, primary care office visit, and x-ray. You 
say that you should not owe these amounts. 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 urgently needed services. Your contract with the Plan also clearly says that you must 
pay a $5 copayment for primary care provider office visits. Your contract with the Plan also clearly says that 
you must pay a $20 copayment for x-rays. 
 
You have been asked to pay a $15 copayment for the urgent care visit provided on March 17, 2022. This 
item/service falls within the urgently needed services benefit category. You have also been asked to pay a $5 
copayment for the primary care provider office visit provided on April 11, 2022. This item/service falls within 
the provider/practitioner services benefit category. You have also been asked to pay a $20 copayment for the x-
ray provided on April 12, 2022. This item/service falls within the outpatient diagnostic tests and therapeutic 
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 copayments for the urgent care visit, 
primary care office visit, and x-ray provided from March 17, 2022, to April 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on February 10, 2023. 
 
You asked the Plan to pay for office 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 office visit provided on 
February 10, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denial with supporting 
documentation. The Plan denied your request. The Plan says that the enrollee does not meet all the 
requirements based on Medicare guidelines. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the complexity of the enrollees nursing, medical and rehabilitation needs requires an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee requires treatment by 
multiple therapies, including physical therapy and occupational therapy, at least three hours a day /five days a 
week. The documentation states that there is reasonable expectation that this enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 waive the cost sharing for the new patient office visit, the foot x-
rays, and the trimming of lesions provided by an out-of-network provider on November 11, 2022, and the 
office visit, the lab services, and the nail biopsies provided by an out-of-network provider on February 14, 
2023. 
 
You asked the Plan to waive the cost sharing for the office visits, the x-rays, the trimming of lesions, the lab 
services, and the nail biopsies. You say that you were told that the provider was in-network. 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% 
coinsurance for each out-of-network Medicare-covered x-ray, a 50% coinsurance for out-of-network Medicare-
covered physician specialist services, and a 50% coinsurance for each out-of-network Medicarecovered lab 
service. 
 
You have been asked to pay a $26.80 coinsurance for the x-rays ($53.62 allowed amount x .50 = $26.80 
rounded down). You have been asked to pay a $183.12 coinsurance for the lab services ($366.25 allowed 
amount x .50 = $183.12). These items/services fall within the outpatient diagnostic tests and therapeutic 
services and supplies benefit category. You have been asked to pay a $125.34 coinsurance for the office visits 
($250.68 allowed amount x .50 = $125.34). You have been asked to pay a $39.38 coinsurance for the trimming 
of lesions ($78.76 allowed amount x .50 = $39.38). You have also been asked to pay a $87.92 coinsurance for 
the nail biopsies ($175.85 allowed amount x .50 = $87.92 rounded down). These items/services fall 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 cost sharing for the new patient office visit, the foot x-rays, and the 
trimming of lesions provided by an out-of-network provider on November 11, 2022, and the office visit, the lab 
services, and the nail biopsies provided by an out-of-network provider on February 14, 2023
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a procedure provided on January 17, 2023. 
 
You asked the Plan to pay for a 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 procedure provided on 
January 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs 
provided on February 21, 2023. 
 
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. You say that you disagree 
with the coinsurance. 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 Medicare Part B prescription drugs. 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 allowed amount for the prescription drugs is $44.60. You are 
being asked to pay $8.92 ($44.60 x 20% = $8.92). Therefore, we decided that the Plan does not have to waive 
the coinsurance for Medicare Part B prescription drugs provided on February 21, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the endoscopy procedure provided on 
March 09, 2023. 
 
You asked the Plan to waive the copayment for the endoscopy procedure. You say that the initial surgery could 
not 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 $200 
copayment for outpatient surgery, including services provided at ambulatory surgical centers. 
 
You have been asked to pay a $200 copayment for the endoscopy procedure. This item/service falls within the 
outpatient surgery, including services provided at ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the endoscopy procedure provided on March 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 10, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of the plans network) will not be 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 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 an office visit provided on January 10, 2023, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on March 28, 2023. 
 
You asked the Plan to pay for the home visit. You say that at the time of service the enrollee was residing in an 
assisted living facility. 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 home visit provided 
on March 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 32653, 31622, and 43215 for date of service 
April 4, 2023. 
 
You asked the Plan to pay for procedure codes 32653, 31622, and 43215. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Therefore, codes 32653 and 31622 cannot be paid as billed. Based on this information, we decided that 
Medicare rules for coverage of services billed with a -59 modifier have not been met. We find that CPT code 
43215 is not supported in the medical record. Specifically, the operative report did not include documentation 
of a flexible esophagoscopic transoral; with removal of foreign body(s); therefore, this code cannot be verified. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 32653, 31622, and 43215 for date 
of service April 4, 2023.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs 
provided on January 01, 2023, to March 31, 2023. 
 
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. You say that you disagree 
with the coinsurance. 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 Medicare Part B prescription drugs. 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 allowed amount for the prescription drugs is $11,400. You are 
being asked to pay $2,280 ($11,400 x 20% = $2,280). Therefore, we decided that the Plan does not have to 
waive the coinsurance for Medicare Part B prescription drugs provided on January 01, 2023, to March 31, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out-of-network office visit provided on 
April 3, 2023. 
 
You asked the Plan to waive the coinsurance for an out-of-network office visit. You say that you went to a 
clinic with a different name and     therefore is in-network. 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% 
coinsurance for Physician/Practitioner services, including doctor's office visits.  
 
The allowed amount of this service is $138.40, resulting in a coinsurance amount of $69.20 ($138.40 x 50% = 
$69.20). You have been asked to pay a $69.20 coinsurance for an out-of-network office visit. This item/service falls 
within the Physician/Practitioner services, including doctor's office visits benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for an out-of-network office visit provided on April 3, 2023.