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

 
We decided that the Plan does not have to reduce the copayment for each psychotherapy session provided on 
May 25, 2023, to July 06, 2023. 
 
You asked the Plan to reduce the copayment for each psychotherapy session. You say that you cannot continue 
the therapy at this 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 $50 
copayment for each out-of-network individual/group Medicare-covered therapy visit. 
 
You have been asked to pay a $50 copayment for each psychotherapy session. This item/service falls within the 
each out-of-network individual/group Medicare-covered therapy visit benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total amount you owe is $200 ($50 
copayment x 4 services = $200). Therefore, we decided that the Plan does not have to reduce the copayment for 
each psychotherapy session provided on May 25, 2023, to July 06, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient surgery provided on June 08, 2023. 
 
You asked the Plan to pay for outpatient surgery. You say that you say that you are contracted with the plans 
network of providers. 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 outpatient surgery 
provided on June 08, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an oxygen concentrator and a portable 
oxygen system provided on January 15, 2023. 
 
You asked the Plan to waive the coinsurance for an oxygen concentrator and a portable oxygen system. You 
say that you disagree with the coinsurance. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for an oxygen concentrator and a portable oxygen system. 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. Therefore, we decided that the Plan 
does not have to waive the coinsurance for an oxygen concentrator and a portable oxygen system provided on 
January 15, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on August 
03, 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 $300 
copayment for outpatient surgery. 
 
You have been asked to pay a $300 copayment for an outpatient surgery. This item/service falls within the 
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. However, since the allowed amount is less than the standard copayment, you only owe $257.86. 
Therefore, we decided that the Plan does not have to waive the copayment for an outpatient surgery provided 
on August 03, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the deductible for the discharge management services 
provided on January 10, 2023. 
 
You asked the Plan to reduce the deductible for the discharge management services. You say that you disagree 
with the deductible. 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 $1,500 deductible which applies to in-network provider and 
professional services. 
 
 
 
 You have been asked to pay $109.53 towards your $1,500 deductible for the discharge management services. 
The item or service you asked the Plan to reduce the deductible for falls within the physician/practitioner 
services, including doctor's office visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $1,500 deductible which applies to physician/practitioner services, 
including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time 
the discharge management services was received on January 10, 2023. Therefore, we decided that the Plan does 
not have to reduce the deductible for the discharge management services provided on January 10, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the cystourethroscopy procedures 
provided on November 28, 2022, and February 23, 2023. 
 
You asked the Plan to waive the copayments for the cystourethroscopy procedures. You say that you disagree 
with the copayments. 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 $300 copayment for outpatient surgery, including services provided at ambulatory surgical centers. 
The enrollees contract with the Plan also clearly says that enrollees must pay a $260 copayment for outpatient 
surgery, including services provided at ambulatory surgical centers. 
 
The enrollee has been asked to pay a $300 copayment for the cystourethroscopy procedure provided on 
November 28, 2022. The enrollee has also been asked to pay a $260 copayment for the cystourethroscopy 
procedure provided on February 23, 2023. These items/services fall within the outpatient surgery, including 
services provided at ambulatory surgical centers benefit category. 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 cystourethroscopy procedures provided on November 28, 2022, and February 23, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0425, A0429) provided on May 10, 
2023. 
 
You asked the Plan to pay for the ambulance services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that diagnosis code R46.2 has an Excludes1 note in relation to diagnosis code 
F99. This means that the two diagnosis codes cannot be reported together. Based on this information, we 
decided that the Medicare billing rules for the ambulance services have not been met. Therefore, we decided 
that the Plan does not have to pay for ambulance services (A0425, A0429) provided on May 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colonoscopy provided on May 04, 2023, to May 17, 
2023. 
 
You asked the Plan to pay for the colonoscopy. You say that you are requesting reconsideration for the services 
provided. 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 colonoscopy 
provided on May 04, 2023, to May 17, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on February 
15, 2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you feel that you should not 
be charged. 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 $265 
copayment for non-emergency ground ambulance trips. 
 
You have been asked to pay a $265 copayment for ambulance services. This item/service falls within the non-
emergency ground ambulance trips 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 $149.67. Therefore, we decided that the Plan does not have to waive the copayment for ambulance 
services provided on February 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 02, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that this service is supported in the 
records. 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 subsequent nursing 
facility care provided on May 02, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a, in-network x-ray provided on June 12, 
2023. 
 
You asked the Plan to waive the copayment for a, in-network x-ray. You say that you should not have to pay 
this large 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 $60 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $60 copayment for a, in-network x-ray. 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. Therefore, we decided that the Plan does not have to waive the copayment for a, in-
network x-ray provided on June 12, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the scanning laser provided on July 19, 
2023. 
 
You asked the Plan to waive the copayment for the scanning laser. You say that you do not believe you should 
have to pay the $40 copay because you did not have to pay it last year and nothing to your knowledge has 
changed from 2022 to 2023 to cause the copay to increase. 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 $40 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $40 copayment for the scanning laser. 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 the scanning laser provided on July 19, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the air ambulance transportation services provided on 
December 2, 2022. 
 
You asked the Plan to pay for the air ambulance transportation. You say that the services were a medical 
emergency. The Plan denied your request. The Plan says there is no mention if emergent surgery was required, 
why ground transportation could not be utilized, and if there was a life-threatening condition that necessitated 
air transport. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 the air ambulance transportation. Our 
reviewer says that the air ambulance transportation services are not medically necessary. Our physician 
reviewer found the enrollee's condition did not have a contraindication to transport via ground. The enrollee did 
not require transport via air to get to the receiving facility faster. The criteria for coverage have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the air ambulance transportation have not been met. Therefore, we decided that 
the Plan does not have to pay for the air ambulance transportation services provided on December 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an out-of-network urgent care visit 
provided on August 17, 2023. 
 
You asked the Plan to reduce the copayment for an out-of-network urgent care visit. You say that while this 
happened out-of-network, you would like to be charged the in-network 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 $60 
copayment for urgently needed services. 
 
You have been asked to pay a $60 copayment for an out-of-network urgent care visit. This item/service falls 
within the urgently needed 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 reduce the copayment for 
an out-of-network urgent care visit provided on August 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the wound care services on May 11, 2023, 
to July 13, 2023.  
 
You asked the Plan to waive the copayment for the wound care services. You say that you were told that the 
copayment would be $45. 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 $290 
copayment for each Medicare-covered outpatient hospital facility visit. The provider billed in the amount of 
$278 and the allowed amount is $205.37. There were four dates of service ($205.37 x 4 = $821.48). The 
provider also billed in the amount of $185 and the allowed amount is $136.91. There were five dates of service 
($136.91 x 5 = $684.55). This is less than the copayment amount. For all dates of service, it's $821.48 + 
$684.55 = $1,506.03. You have been asked to pay a $290 copayment for each wound care service. 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. However, since the allowed amount is less than the standard copayment, you only owe 
$1,506.03. Therefore, we decided that the Plan does not have to waive the copayment for the wound care 
services on May 11, 2023, to July 13, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF offers physical therapy three times per day 
while the skilled nursing facility does not offer the physical therapy you need. The Plan denied your request. 
The Plan says the request is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit, and related services provided on May 12, 2023. 
 
You asked the Plan to pay for a home visit, and related services. You say that it was indicated that a referral or 
authorization was not required for the services rendered. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home visit, and related 
services provided on May 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for an occupational therapy and the finger 
orthosis provided on February 10, 2023. 
 
You asked the Plan to reduce the cost share for an occupational therapy and the finger orthosis. You say that 
you disagree with 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 a $25 
copayment for each Medicarecovered occupational therapy service. Your contract with the Plan also clearly 
says that you must pay 20% coinsurance for each Medicarecovered durable medical equipment item. 
 
You have been asked to pay a $20.51, which is less than the standard copayment for the occupational therapy. 
This item/service falls within the outpatient rehabilitation 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.  
 
You have also been asked to pay $43.46, which is 20% coinsurance of the allowed amount for the finger 
orthosis ($217.32 allowed amount x 20% = $43.46). 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. Therefore, we decided that the Plan does not have to reduce the cost share for an 
occupational therapy and the finger orthosis provided on February 10, 2023.