Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the mental health care services provided on 
February 01, 2023. 
 
You asked the Plan to waive the copayment for the mental health care services. You say that you did not see 
this provider. 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 $30 
copayment for in-network outpatient mental health care. 
 
You have been asked to pay a $30 copayment for the mental health care services. This item/service falls within 
the in-network 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. The records show you were seen for mental health care services on 
February 1, 2023. Therefore, we decided that the Plan does not have to waive the copayment for the mental 
health care services provided on February 01, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for surgery services provided on December 06, 
2022. 
 
You asked the Plan to waive the copayment for surgery services. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for outpatient hospital services/surgery services. 
 
You have been asked to pay a $200 copayment for surgery services. This item/service falls within the 
outpatient hospital services/surgery 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 surgery services provided on December 06, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on January 16, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you didn't 
call the ambulance as it was at the casino. You also say that you used the ambulance services but they did not 
transport you. The Plan denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 16, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on January 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on June 07, 2022. 
 
You asked the Plan to pay for lab testing. 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 lab testing provided on 
June 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transthoracic echocardiogram (TTE) provided on 
December 2, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the transthoracic echocardiogram (TTE). You say that this service was medically 
necessary. The Plan denied your request. The Plan says enrollees must receive their care from a network 
provider. 
 
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 item/service 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 this item/service. Therefore, 
we decided that the Plan does not have to pay for the transthoracic echocardiogram (TTE) provided on 
December 2, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 18, 2023. 
 
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 January 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  an office visit provided on December 14, 2022, by an out-
of-network (OON) provider.  
 
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 this was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 December 14, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
February 06, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that the provider was not a 
specialist. 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 physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $25 copayment for the specialist office visit. This item/service falls 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 copayment for the specialist office visit provided on February 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each office visit provided on February 24, 
2023, to February 26, 2023. 
 
You asked the Plan to waive the copayment for each office visit. You say that you do not agree with paying 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 $25 
copayment for specialist visits, including outpatient clinic visits. 
 
You have been asked to pay a $25 copayment for each office visit. This item/service falls within the specialist 
visits, including outpatient clinic 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 $75 ($25 copayment x 3 visits = $75). 
Therefore, we decided that the Plan does not have to waive the copayment for each office visit provided on 
February 24, 2023, to February 26, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 31, 
2023, through February 1, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary.   
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 pay for these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee underwent an elective left total knee arthroplasty on January 31, 2023. He 
tolerated the procedure without complication and was discharged home on February 1, 2023. The procedure is 
currently approved as an ambulatory procedure. The review has determined that the record did not show that at 
the time of the inpatient admission the admitting physician reasonably expected that the enrollees necessary 
hospital care (including earlier emergency department (ED) and/or observation care) would span two 
midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from January 31, 2023, through February 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic eye exam provided on March 
16, 2023. 
 
You asked the Plan to waive the copayment for the diagnostic eye exam. You say that you cannot tell when you 
will have a copayment or not. 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 $35 
copayment for diagnostic vision care. 
 
You have been asked to pay a $35 copayment for the diagnostic eye exam. This item/service falls within the 
diagnostic vision 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 
diagnostic eye exam provided on March 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the specialist office visit provided on 
March 20, 2023. 
 
You asked the Plan to reduce the copayment for the specialist office visit. You say that you only saw a nurse 
practitioner, not a specialist. 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 $35 
copayment for each in-person specialist visit. 
 
You have been asked to pay a $35 copayment for the specialist 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 reduce the copayment for the specialist office visit provided on March 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic hearing exam provided on 
February 24, 2023. 
 
You asked the Plan to waive the copayment for the diagnostic hearing exam. You say that you had asked for a 
routine hearing exam. 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 $35 
copayment for diagnostic hearing services. 
 
You have been asked to pay a $35 copayment for the diagnostic hearing exam. This item/service falls within 
the diagnostic hearing services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The records show a diagnostic hearing exam was provided, and the copayment 
was applied correctly. Therefore, we decided that the Plan does not have to waive the copayment for the 
diagnostic hearing exam provided on February 24, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the chest x-ray provided on December 20, 
2022. 
 
You asked the Plan to waive the deductible for the chest x-ray. You say that your Plan contract says you should 
only have a $15 copayment for x-rays. 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 in-network x-rays. Your contract 
with the Plan also says that enrollees must pay a $15 copayment after meeting the deductible for in-network x-
rays. 
 
 You have been asked to pay $30.96 towards the deductible. The item or service you asked the Plan to waive the 
deductible for falls within the in-network outpatient diagnostic x-rays benefit category. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to in-network 
outpatient diagnostic x-rays. This cost sharing is a contractual obligation that had not been met at the time the 
chest x-ray was received on December 20, 2022. Therefore, we decided that the Plan does not have to waive 
the deductible for the chest x-ray provided on December 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam provided on March 09, 2023. 
 
You asked the Plan to waive the copayment for the eye exam. You say that this service should have a $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 a $30 
copayment for vision care. 
 
You have been asked to pay a $30 copayment for the eye exam. This item/service falls within the vision 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 eye exam provided on March 
09, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically necessary. This enrollee may benefit from bilevel positive airway pressure (BiPAP) with average volume-
assured pressure support (AVAPS) during sleep as an outpatient. Consideration should be given to attended 
polysomnography with BiPAP titration, as it appears the home sleep study has underestimated the sleep 
disordered breathing. Medicare does not cover a home ventilator when used at settings that can be provided 
with BiPAP.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the myocardial perfusion imaging, the 
essential diagnostic component, and the regadenoson injection provided on January 12, 2023 
 
You asked the Plan to waive the cost share for the myocardial perfusion imaging, the essential diagnostic 
component, and the injection. You say that the items should be covered under the test. 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 
copayment for Medicare-covered non-radiological diagnostic services. Your contract with the Plan also clearly 
says that you must pay 20% coinsurance for each Medicare-covered medical supply. Your contract with the 
Plan also clearly says that you must pay 5% coinsurance for each Medicare-covered Part B drug. 
 
You have been asked to pay a $10 copayment for the myocardial perfusion imaging. 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.  
 
 You have also been asked to pay $134.40, which is 20% coinsurance of the allowed amount for the essential 
diagnostic component ($672 allowed amount x 20% = $134.40). This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. You have also been asked to pay $12.27 
which is 5% coinsurance of the allowed amount for the injection ($245.40 allowed amount x 5% = $12.27) 
This item/service falls within the Medicare Part B prescription drugs benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the cost share for the myocardial perfusion imaging, the essential diagnostic 
component, and the regadenoson injection provided on January 12, 2023
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
January 1, 2023, to January 7, 2023.  
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the enrollee was 
discharged too soon from the hospital and had to go back. 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 $260 copayment per day for days 1-5 of each in-network inpatient hospital stay. The enrollees 
contract with the Plan also clearly says that enrollees then pay a $0 copayment per day for any additional days 
of the same in-network inpatient hospital stay. 
 
The enrollee has been asked to pay a $260 copayment per day for days 1-5 of the inpatient hospital stay. This 
item/service falls within the inpatient hospital care benefit category. The enrollee has not been asked to pay 
after day five or for the day of discharge. The enrollee has been asked to pay a total of $1,300 ($260 copayment 
per day x 5 days = $1,300). 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 copayment for the inpatient hospital 
stay provided from January 1, 2023, to January 7, 2023.