Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the knee brace provided on September 20, 
2022. 
 
You asked the Plan to waive the coinsurance for the knee brace. You say that you returned the brace the same 
day. 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 prosthetic devices and related supplies. 
 
You have been asked to pay 20% coinsurance for the knee brace. This item/service falls within the prosthetic 
devices and related 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 total you owe is $100.35 ($501.75 allowed amount x 20% = $100.35). Therefore, we 
decided that the Plan does not have to waive the coinsurance for the knee brace provided on September 20, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the specialist office visit and the ECG 
provided on September 29, 2022. 
 
You asked the Plan to waive the copayments for the specialist office visit and the ECG. You say that the claim 
should be processed at the in-network 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $35 copayment for services obtained from a specialist. The enrollees contract with the Plan also 
clearly says that enrollees must pay a $20 copayment for Medicare-covered non-radiological diagnostic 
services. 
 
The enrollee has been asked to pay a $35 copayment for the specialist office visit. This item/service falls within 
the physician/practitioner services, including doctors office visits benefit category. The enrollee has also been 
asked to pay $14.62, which is less than the standard copayment for the ECG. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and supplies benefit category. The enrollee has been asked 
to pay a total of $49.62 ($35 copayment + $14.62 copayment = $49.62). 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 copayments for the specialist office visit and the electrocardiogram provided on September 
29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance image (MRI) 
provided on February 08, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance image (MRI). You say that you were 
advised by the facility that you did not have a copayment for the MRI. 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 diagnostic test. 
 
You have been asked to pay a $200 copayment for a magnetic resonance image (MRI). This item/service falls 
within the outpatient diagnostic test 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 a 
magnetic resonance image (MRI) provided on February 08, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a wrist brace provided on December 14, 
2022. 
 
You asked the Plan to waive the coinsurance for a wrist brace. You say that you never used this item. 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 prosthetic devices and related supplies. 
 
You have been asked to pay 20% coinsurance for a wrist brace. This item/service falls within the prosthetic 
devices and related 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 total you owe is $30 ($150 allowed amount x 20% = $30). Therefore, we decided that 
the Plan does not have to waive the coinsurance for a wrist brace provided on December 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for MRIs provided on January 04, 2023, to 
January 05, 2023. 
 
You asked the Plan to waive the copayment for MRIs. You say that you should not have to pay for two MRIs, 
they should have been done on the same day. 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 $95 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $95 copayment for MRIs. 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 total you owe is $190 ($95 copayment x 2/MRIs = $190). 
Therefore, we decided that the Plan does not have to waive the copayment for MRIs provided on January 04, 
2023, to January 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist services provided on January 
10, 2023. 
 
You asked the Plan to waive the copayment for the specialist services. You say that you were told by the 
provider that there would be no copayment. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 
copayment for specialist physician/practitioner services. 
 
You have been asked to pay a $15 copayment for the specialist services. 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 services provided on January 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for gingival irrigation, fixed partial denture sectioning, 
drugs or medicaments dispensed in the office for home use, a cleaning, immediate maxillary/mandibular partial 
denture, and dental extraction (D4341, D5221, D5222, D7210, D4921, D9630, D9120) provided on October 6, 
2021, to December 29, 2021. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the cost-sharing applied correctly based 
on the services provided. Coverage for the gingival irrigation, fixed partial denture sectioning, and drugs or medicaments dispensed in the office for home use (D4921, D9630, D9120) denied correctly as they do not fall 
within your dental 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, gingival irrigation, fixed partial 
denture sectioning, or drugs or medicaments dispensed in the office for home use are not among those covered 
under this benefit.    
 
You have been asked to pay a 50% coinsurance for a cleaning, immediate maxillary/mandibular partial denture, 
and dental extraction. These services fall within the Dental 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 pay more for gingival irrigation, fixed partial denture sectioning, drugs or medicaments dispensed in the 
office for home use, a cleaning, immediate maxillary/mandibular partial denture, and dental extraction (D4341, 
D5221, D5222, D7210, D4921, D9630, D9120) provided on October 6, 2021, to December 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on 
January 19, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 February 11, 2021. 
Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided 
on January 19, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the echocardiogram (EKG) provided on 
January 06, 2023. 
 
You asked the Plan to waive the copayment for the echocardiogram (EKG). You say that this was not the 
provider you had seen for your 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 $20 
copayment for outpatient diagnostic tests, including EKGs. 
 
You have been asked to pay a $20 copayment for the echocardiogram (EKG). This item/service falls within the 
outpatient diagnostic tests, including EKGs 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 $14.70. Therefore, we decided that the Plan does not have to waive the copayment for the 
echocardiogram (EKG) provided on January 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visits provided on May 30, 2022, to August 04, 2022. 
 
You asked the Plan to pay for office visits. You say that you were unable to obtain a physician. 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 visits provided on 
May 30, 2022, to August 04, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computerized tomography (CT) scan and 
outpatient surgery on March 03, 2022, to July 05, 2022.  
 
You asked the Plan to waive the copayment for CT scan and outpatient surgery. You say that you would like 
the copay waived as they are too high for you to afford on a limited 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 $250 
copayment per day for other Medicare-covered diagnostic radiology services that are not ultrasounds. You will 
only pay one copayment per day even if multiple diagnostic radiology services are performed. Covered 
services include, but are not limited to diagnostic radiology services, such as ultrasound, nuclear cardiac 
imaging, PET, MRI, and CT scan. You must pay a $250 copayment per day for other outpatient procedures and 
services, including, but not limited to, diagnostic and therapeutic endoscopy, and outpatient surgery performed 
in an outpatient hospital or ambulatory surgical center. If you are having surgery in a hospital facility, you 
should check with your provider about whether you will be an inpatient or outpatient. Unless the provider 
writes an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost-sharing 
amounts for outpatient surgery. Even if you stay in the hospital overnight, you might still be considered an 
outpatient. There were 3 visits. 3 x $250 = $750.00. $250 + $750 = $1,000. Therefore, results in the total cost 
sharing amount of $1,000. 
 
You have been asked to pay a $250 copayment for CT scan and a $250 copayment per outpatient surgery. This 
item/service falls within the outpatient diagnostic tests and therapeutic services and supplies and Outpatient 
surgery, including services provided at hospital outpatient facilities and 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 computerized tomography (CT) scan and 
outpatient surgery on March 03, 2022, to July 05, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the wound debridement services provided 
on November 07, 2022, to November 21, 2022. 
 
You asked the Plan to waive the copayment for the wound debridement services. You say that you would like 
to appeal the copayment 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 $250 
copayment for in-network outpatient hospital services. 
 
You have been asked to pay a $250 copayment for the wound debridement 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. Therefore, we decided that the Plan does not have to waive the 
copayment for the wound debridement services provided on November 07, 2022, to November 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on January 11, 2023. 
 
You asked the Plan to pay for laboratory testing. You say that we depend on the facility staff to verify 
eligibility and 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 laboratory testing 
provided on January 11, 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 January 20, 
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 January 20, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for chemotherapy treatment provided on 
January 26, 2023. 
 
You asked the Plan to waive the cost share for chemotherapy treatment. You say that you have had this 
procedure previously and had $0 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 and a $300 copayment for services or items other than surgery, 
including but not limited to Part B drugs.  
 
You have been asked to pay a $1,758.06 for chemotherapy treatment.  
 
Date of Service Service Rendered Total 
Allowed 
Amount Per 
Contract 
Cost Share 
January 26, 2023 Injection of additional new drug 
(96375) 
$147.87 $300 
copayment 
$30.00 
(less than standard 
copayment) 
January 26, 2023 Rituximab injection  
(J9312) 
$8,174.80 20% 
coinsurance 
$1,634.96 
January 26, 2023 Administration of chemotherapy, 
1 hour of less  
(96413) 
$386.98 20% 
coinsurance 
$77.40 
January 26, 2023 Administration of chemotherapy, 
each additional hour  
(96415) 
$78.50 20% 
coinsurance 
$15.70 
Total    $1758.06 
 
 
The Medicare Part B drug and administration of that drug falls within the Medicare Part B prescription drugs 
benefit category. The injection of additional new drug falls within the outpatient surgery and other medical 
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 cost share for chemotherapy treatment 
provided on January 26, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cystourethroscopy provided on 
February 13, 2023. 
 
You asked the Plan to waive the copayment for the cystourethroscopy. You say that you did not know you 
would have a copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copayment for outpatient surgery, including services provided at ambulatory surgical centers. 
 
You have been asked to pay a $150 copayment for the cystourethroscopy. 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 cystourethroscopy provided on February 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics (L3649). 
 
You asked the Plan to pay for foot orthotics. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
 
  Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition.  Therefore, we decided that the Plan does not have to pay for foot 
orthotics (L3649).