Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to increase the reimbursement for the hospital care provided from May 
22, 2023, to May 25, 2023. 
 
You asked the Plan to increase the reimbursement for the hospital care. You say that you should be reimbursed 
more. The Plan denied your request. The Plan says that you were reimbursed the correct amount. 
 
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 $125 
copayment for out-of-network plan-covered emergency services received outside the United States and its 
territories. 
 
 You have been asked to pay a $125 copayment for the hospital care. This item/service falls within the 
emergency care (worldwide) benefit category. The record shows you should only be reimbursed $22,468.25, 
which is the maximum allowable amount. This means that you have been reimbursed 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 increase the reimbursement for the 
hospital care provided from May 22, 2023, to May 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for each hospital care service provided on 
May 24, 2023, to May 27, 2023. 
 
You asked the Plan to reduce the copayment for each hospital care service. You say that were under the 
impression 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 $25 
copayment for out-of-network physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $25 copayment for each hospital care service. 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. The total amount you owe is $100 ($25 
copayment x 4 services = $100). Therefore, we decided that the Plan does not have to reduce the copayment for 
each hospital care service provided on May 24, 2023, to May 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87801, 87500, 87150) provided on September 
26, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87801, 87500, and 87150 are not supported in the medical record. Specifically, 
multiple unbundled codes were billed for a single panel. There is a single code that best describes this panel 
(0369U). Based on this information, we decided that Medicare rules for coverage of the lab services have not 
been met. Therefore, we decided that the Plan does not have to pay for lab services (87801, 87500, 87150) 
provided on September 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the remote monitoring services provided 
on June 30, 2022. 
 
You asked the Plan to waive the coinsurance for the remote monitoring services. You say that the services were 
not rendered. 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 50% 
coinsurance for out-of-network physician/practitioner services, including doctors office visits.  
You have been asked to pay 50% coinsurance for the remote monitoring services. 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. The total amount you owe is $61.39 
($122.79 x 50% = $61.39). Therefore, we decided that the Plan does not have to waive the coinsurance for the 
remote monitoring services provided on June 30, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on January 09, 2023. 
 
You asked the Plan to pay for psychotherapy. 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 psychotherapy provided 
on January 09, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on April 17, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you disagree 
with the copayment applied. 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 tests. 
 
You have been asked to pay a $200 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic tests 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 $135.87, which is less than the standard copayment 
for a CT scan. Therefore, we decided that the Plan does not have to waive the copayment for a computed 
tomography (CT) scan provided on April 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) provided on 
May 2, 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 August 27, 2021. 
Therefore, we decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) 
provided on May 2, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on July 14, 2023. 
 
You asked the Plan to pay for the home visit. You say that you are appealing the claim payment denial. 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 July 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the end-stage renal disease services provided on August 01, 
2023. 
 
You asked the Plan to pay for the end-stage renal disease services. 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 the end-stage renal 
disease services provided on August 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit and the podiatry services provided on August 
03, 2022. 
 
You asked the Plan to pay for the home visit and the podiatry services. 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 the home visit and the 
podiatry services provided on August 03, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the arthroplasty procedure provided on 
July 11, 2023. 
 
You asked the Plan to waive the coinsurance for the arthroplasty procedure. You say that you were not told of 
the cost share. 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 arthroplasty 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 total amount you owe 
is $2,335.52 ($11,677.61 allowed amount x 20% = $2,335.52). Therefore, we decided that the Plan does not 
have to waive the coinsurance for the arthroplasty procedure provided on July 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the remote monitoring services provided 
on August 31, 2022. 
 
You asked the Plan to waive the coinsurance for the remote monitoring services. You say that the services were 
not rendered. 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 50% 
coinsurance for out-of-network physician/practitioner services, including doctors office visits.  
You have been asked to pay 50% coinsurance for the remote monitoring services. 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. The total amount you owe is $42.32 
($84.64 allowed amount x 50% = $42.32). Therefore, we decided that the Plan does not have to waive the 
coinsurance for the remote monitoring services provided on August 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the outpatient visit on July 19, 2023. 
 
You asked the Plan to waive the cost share for the outpatient visit. You say that that you shouldn't be 
responsible for this payment since you were advised that colonoscopies are covered at 100% and this is a 
required service for you to receive this colonoscopy. You believe that the bill shouldn't be your responsibility 
since the service was a pre-cursor to a colonoscopy. 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 10% 
coinsurance of the approved amount. The annual deductible applies. There is a $10.78 coinsurance and a 
$97.06 deductible. For the service it's $10.78 + $97.06 = $107.84. Therefore, results in the total cost sharing 
amount of $107.84. 
 
You have been asked to pay a $107.84 cost share for the outpatient visit. This item/service falls within the 
doctor and other health care provider 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 the outpatient visit on July 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit for the evaluation and management of an 
established patient provided on June 28, 2023. 
 
You asked the Plan to pay for home visit for the evaluation and management of an established patient. You say 
that you are requesting reconsideration for 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 home visit for the 
evaluation and management of an established patient provided on June 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on July 06, 
2023. 
 
You asked the Plan to waive the copayment for an outpatient surgery. 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 $150 
copayment for outpatient surgery/Medicare-covered outpatient surgery. 
 
You have been asked to pay a $150 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/Medicare-covered outpatient surgery 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 outpatient surgery provided on July 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care (99223, 99232) provided on March 21, 2023 to 
March 23, 2023. 
 
You asked the Plan to pay for the inpatient care. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of codes 99223, & 99232 are Initial hospital inpatient or 
observation care, per day, for the evaluation and management of a patient and subsequent hospital care for the 
evaluation and 
management of a patient. 
 We find that CPT codes 99223, & 99232 are not supported in the medical record. Specifically, there are no 
evaluation and management notes provided for the dates of service billed. The records provided are for other 
dates. Based on this information, we decided that Medicare rules for coverage of the inpatient care have not 
been met. Therefore, we decided that the Plan does not have to pay for inpatient care (99223, 99232) provided 
on March 21, 2023 to March 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy provided on February 09, 2023. 
 
You asked the Plan to pay for the psychotherapy. 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 the psychotherapy 
provided on February 09, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network x-ray provided on June 22, 
2023. 
 
You asked the Plan to waive the copayment for an in-network x-ray. You say that you were told this would be 
covered 100%. 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 diagnostic tests and therapeutic services andsupplies. 
 
You have been asked to pay a $150 copayment for an in-network x-ray. This item/service falls within the 
outpatient diagnostic tests and therapeutic services andsupplies 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 $79.15. Therefore, we decided that the Plan does not have to waive the 
copayment for an in-network x-ray provided on June 22, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan, lower extremity 
provided on July 03, 2023. 
 
You asked the Plan to pay for the computed tomography (CT) scan, lower extremity. You say that you are 
appealing the claim payment denial. 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 computed 
tomography (CT) scan, lower extremity provided on July 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on April 24, 2023. 
 
You asked the Plan to pay for the office visit. You say that you say that the service was medically necessary. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on April 24, 2023.