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

 
We decided that the Plan does not have to waive the copayment for ambulance service provided on January 13, 
2023. 
 
You asked the Plan to waive the copayment for ambulance service. You say that you are disputing the share 
cost. 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 ambulance service. 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 service 
provided on January 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213 provided on January 9, 2023. 
 
You asked the Plan to pay for procedure code 99213. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment is included in the global surgery 
payment. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 
We looked at the file and Medicare rules. Payment for procedure code 99213 is included in the global surgery 
payment for procedure code 20610 provided on the same day. Separate payment cannot be made for procedure 
code 99213. It is inappropriate to use modifier 24 for services rendered on the same day as the procedure. 
Based on this information, we decided that Medicare rules for coverage of procedure code 99213 have not been 
met.  Therefore, we decided that the Plan does not have to pay for procedure code 99213 provided on January 
9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 26, 2022. 
 
You asked the Plan to pay for laboratory 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 laboratory services 
provided on December 26, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
January 16, 2023, to January 17, 2023. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you did not receive 
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 $90 
copayment for in-network and out-of-network emergency care. 
 
You have been asked to pay a $90 copayment for the emergency room visit. This item/service falls within the 
in-network and out-of-network 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. The records show you were seen in the emergency department. 
Therefore, we decided that the Plan does not have to waive the copayment for the emergency room visit 
provided on January 16, 2023, to January 17, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provide from 
January 9, 2023, to January 10, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you never received 
these services and stayed in the waiting room. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $65 
copayment per day, for days 1 to 5 and a $0 copayment per day, for days 6 to 90 for each admission to inpatient 
hospital care.  
 You have been asked to pay a $65 copayment for 1 day of the inpatient hospital stay. You have not been 
charged for any additional days. 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 inpatient hospital stay provide from January 9, 2023, to 
January 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96372 provided on January 10, 2023. 
 
You asked the Plan to pay for procedure code 96372. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 We looked at the file and Medicare rules. In this case, the enrollee received services (96372) while in an 
outpatient hospital setting. Per Medicare payment guidelines, code 96372 has a PC/TC indicator of 5 and 
payment may not be made for this code when provided to patients in an outpatient hospital setting. Therefore, 
we decided that the Plan does not have to pay for procedure code 96372 provided on January 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 17, 2022. 
 
You asked the Plan to pay for an office visit. 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 provided 
on October 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation and cleaning (D0120, D1110) 
provided on January 24, 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 the services 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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a periodic 
oral evaluation and cleaning (D0120, D1110) provided on January 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an incisional biopsy of oral tissue-soft, excision of a benign 
lesion, and the inhalation of nitrous oxide/analgesia (D9230, D7286, D7410) provided on July 20, 2022. 
 
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 the services 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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
incisional biopsy of oral tissue-soft, excision of a benign lesion, and the inhalation of nitrous oxide/analgesia 
(D9230, D7286, D7410) provided on July 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the abdominal ultrasound provided on 
February 09, 2023. 
 
You asked the Plan to waive the copayment for the abdominal ultrasound. 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 $165 
copayment for in-network outpatient diagnostic radiology, including ultrasounds. 
 
You have been asked to pay a $165 copayment for the abdominal ultrasound. This item/service falls within the 
in-network outpatient diagnostic radiology, including ultrasounds 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 $123.59. Therefore, we decided that the Plan does not have to waive the 
copayment for the abdominal ultrasound provided on February 09, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additonal intraoral x-ray and crown (D0230, D2740) 
provided on November 12, 2022. 
 
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 intraoral x-ray was exhausted 
on the appealed claim. Coverage for the dental crown 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 18, 2022 and 
November 12, 2022. Therefore, we decided that the Plan does not have to pay for an additonal intraoral x-ray 
and crown (D0230, D2740) provided on November 12, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each ultrasound service provided on 
January 06, 2022, to June 25, 2022. 
 
You asked the Plan to waive the copayment for each ultrasound service. You say that you were told this would 
be covered in full. 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 diagnostic tests, including ultrasounds. 
 
You have been asked to pay a $50 copayment for each ultrasound service. This item/service falls within the in-
network outpatient diagnostic tests, including ultrasounds 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. You have been asked to pay a $50 copayment for 
the pelvic ultrasound provided on January 6, 2022. You have also been asked to pay a $50 copayment for the 
breast ultrasound provided on June 11, 2022. Therefore, we decided that the Plan does not have to waive the 
copayment for each ultrasound service provided on January 06, 2022, to June 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the lumbar device provided on January 17, 
2023. 
 
You asked the Plan to waive the coinsurance for the lumbar device. You say that this device was not helpful 
and you could not return it. 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 durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the lumbar device. This item/service falls within the durable 
medical equipment 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 $174.93 ($874.64 allowed amount  x 20% coinsurance 
= $174.93). Therefore, we decided that the Plan does not have to waive the coinsurance for the lumbar device 
provided on January 17, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound provided on May 31, 2022. 
 
You asked the Plan to waive the copayment for ultrasound. You say that you are disputing the share cost. 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 ultrasound. 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 ultrasound provided on May 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a abutment supported porcelain/ceramic crown (D6058) 
provided on March 8, 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 the services 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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
abutment supported porcelain/ceramic crown (D6058) provided on March 8, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
January 21, 2023. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that they only wrapped up 
your leg and sent you home. 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 $75 
copayment for emergency care. 
 
You have been asked to pay a $75 copayment for the emergency room visit. This item/service falls within the 
emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room visit 
provided on January 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on June 22, 2022. 
 
You asked the Plan to pay for lab testing. You say that you say the care should be covered due to the service 
providers negligence to request a referral. 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 
June 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the endoscopy procedure provided on 
January 18, 2023. 
 
You asked the Plan to waive the cost share for the endoscopy procedure. You say that you are being charged 
more than expected. 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 surgery services provided at an 
ambulatory surgical center. Your contract with the Plan also says that there is a $200 copayment once the 
deductible has been met for surgery services provided at an ambulatory surgical center 
 
 You have been asked to pay $484.24, which satisfies the remainder of your deductible. 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 ambulatory surgical centers. This cost sharing is a contractual 
obligation that had not been met at the time the endoscopy procedure was received on January 18, 2023. 
 
You have also been asked to pay a $169.76 copayment, which is less than the standard copayment for the 
endoscopy procedure. You have been asked to pay a total of $654 ($484.24 deductible + $169.76 copayment = 
$654). The item or service you asked the Plan to waive the cost share for 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 cost share for the endoscopy procedure provided on January 18, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on November 29, 2022. 
 
You asked the Plan to pay for an x-ray. 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 an x-ray provided on 
November 29, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for endoscopy provided on November 23, 
2021. 
 
You asked the Plan to waive the copayment for endoscopy. You say that you believe the services should be 
covered because you need to be checked regularly. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment for outpatient hospital services. 
 
You have been asked to pay a $100 copayment for endoscopy. This item/service falls within the 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 endoscopy provided 
on November 23, 2021.