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

 
We decided that the Plan does not have to pay for skilled nursing facility services provided on October 06, 
2022, to October 31, 2022. 
 
You asked the Plan to pay for skilled nursing facility services. You say that this was medically necessary and 
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 skilled nursing facility 
services provided on October 06, 2022, to October 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for external electrocardiographic (ECG) recording provided on 
October 03, 2022. 
 
You asked the Plan to pay for external electrocardiographic (ECG) recording. You say that this 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 external 
electrocardiographic (ECG) recording provided on October 03, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the hospital observation services provided 
on November 09, 2022. 
 
You asked the Plan to reduce the copayment for the hospital observation services. You say that there were 
issues with this claim and you believe you should only owe the $90 emergency room 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 hospital observation. 
 
You have been asked to pay a $300 copayment for the hospital observation services. This item/service falls 
within the outpatient hospital observation 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 medical records show observation services were provided. The 
emergency room copayment has been waived and you only are being charged the outpatient hospital 
observation copayment. Therefore, we decided that the Plan does not have to reduce the copayment for the 
hospital observation services provided on November 09, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the specialist office visit and drug injection 
provided on December 16, 2022. 
 
You asked the Plan to waive the cost share for the specialist office visit and drug injection. You say that 
Medicare paid this service in full in the past. 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 office visits. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B drugs. 
 
You have been asked to pay a $25 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner services benefit category. You have also been asked to pay $78.69, which is 20% 
coinsurance of the allowed amount for the drug injection ($393.46 allowed amount x 20% coinsurance = 
$78.69). You have been asked to pay a total of $103.69 ($25 copayment + $78.69 coinsurance = $103.69). 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 specialist office visit and drug injection provided on 
December 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the screening mammogram provided on 
December 06, 2022. 
 
You asked the Plan to waive the coinsurance for the screening mammogram. You say that screening 
mammograms should 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 40% 
coinsurance for out-of-network breast cancer screenings. 
 
You have been asked to pay 40% coinsurance for the screening mammogram. This item/service falls within the 
out-of-network breast cancer screenings 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 the screening mammogram provided on December 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam provided on December 01, 2022. 
 
You asked the Plan to pay for the eye exam. You say that the test was not performed on this visit. 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 eye exam provided 
on December 01, 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 
September 21, 2022. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you were told to go to 
the ER by your doctor. 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 emergency care. 
 
You have been asked to pay a $90 copayment for the emergency room visit. This item/service falls within the 
in-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. Therefore, we decided that the Plan does not have to waive the copayment for the 
emergency room visit provided on September 21, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided on 
November 01, 2022, to November 30, 2022. 
 
You asked the Plan to pay for the skilled nursing facility (SNF) care. You say that these services do not require 
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 the skilled nursing 
facility (SNF) care provided on November 01, 2022, to November 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the podiatry service provided on February 
28, 2023. 
 
You asked the Plan to waive the copayment for the podiatry service. You say that you only received a nail 
trimming service. 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 in-network podiatry services. 
 
You have been asked to pay a $35 copayment for the podiatry service. This item/service falls within the in-
network podiatry services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the podiatry 
service provided on February 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the breast prosthesis and bra provided on 
July 14, 2022. 
 
You asked the Plan to waive the cost share for the breast prosthesis and bra. You say that you were told this 
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. Your 
contract with the Plan says that there is a $500 combined in-network and out-of-network deductible which 
applies to out-of-network durable medical equipment. Your contract with the Plan also clearly says that you 
must pay 30% coinsurance after meeting the Plan deductible for out-of-network durable medical equipment. 
 
 The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 combined in-
network and out-of-network deductible which applies to out-of-network durable medical equipment. This cost 
sharing is a contractual obligation that had not been met at the time the breast prosthetic and bra were provided 
on July 14, 2022.  
 
You have also been asked to pay 30% coinsurance for the breast prothesis and bra. These items/services fall 
within the durable medical equipment 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 
breast prosthesis and bra provided on July 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on January 25, 2023. 
 
You asked the Plan to pay for telehealth services. You say that you would like for these services to be 
reconsidered. 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 telehealth services 
provided on January 25, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy services provided on November 15, 
2022. 
 
You asked the Plan to pay for home infusion therapy services. You say that this 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 home infusion therapy 
services provided on November 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the specialist office visits, and drug 
injections provided from January 11, 2023, to January 25, 2023. 
 
You asked the Plan to waive the cost share for the specialist office visits and drug injections. You say that the 
provider broke up how they charged the services on these claims. 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-network specialist office visits. Your contract with the Plan also clearly says that you must pay 20% coinsurance for in-network Medicare Part B drugs. 
 
You have been asked to pay a $35 copayment for each specialist office visit. These items/services fall within 
the physician/practitioner services benefit category. You have also been asked to pay $52.36 for each drug 
injection, which is 20% coinsurance of the allowed amount ($261.78 allowed amount x 20% coinsurance = 
$52.36). These items/services fall within the Medicare Part B 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 specialist office visits, and drug injections provided from January 11, 2023, to 
January 25, 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 February 09, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you have 
received numerous CT scans in the past and do not recall being charged a copayment. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $160 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $160 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic test benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a 
computed tomography (CT) scan provided on February 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CT scan provided on November 10, 2022. 
 
You asked the Plan to pay for CT scan. 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 CT scan provided on 
November 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the therapy visit provided on May 31, 
2022. 
 
You asked the Plan to waive the copayment for the therapy visit. You say that you were told you would not 
have a copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for in-network outpatient mental health care. 
 
You have been asked to pay a $20 copayment for the therapy visit. 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. Therefore, we decided that the Plan does not have to waive the copayment for the therapy 
visit provided on May 31, 2022.
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 
November 10, 2022. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you did not think you 
would have to make a copayment for this service. 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 specialist physician/practitioner services.  
You have been asked to pay a $30 copayment for the specialist office visit. This item/service falls within the 
specialist physician/practitioner services benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for the specialist office visit provided on November 10, 2022.
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 
October 6, 2022, to October 10, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you feel this 
copayment is too high. 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 $395 
copayment per day for days 1-5 of each inpatient hospital stay. Your contract with the Plan also clearly says 
you then pay a $0 copayment per day for additional days of the same admission. You have been asked to pay a $395 copayment per day for days 1-3 of the inpatient hospital stay. This 
item/service falls within the inpatient hospital care benefit category. You have not been charged for the day you 
were discharged. You have been asked to pay a total of $1,185 ($395 copayment per day x 3 days $1,185). 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 provided from October 6, 2022, to 
October 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cardiac stress test provided on 
September 06, 2022. 
 
You asked the Plan to waive the copayment for the cardiac stress test. You say that you have never had to pay 
so much for this type of procedure. 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 in-network outpatient diagnostic radiology services. 
 
You have been asked to pay a $150 copayment for the cardiac stress test. This item/service falls within the in-
network outpatient diagnostic radiology services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for the cardiac stress test provided on September 06, 2022.