Persius/hicric huggingface dataset:
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 14, 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 14, 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 on July 
16, 2023, to July 19, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were only in 
observation. 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 $360 
copayment for inpatient hospital care. 
 
You have been asked to pay a $360 copayment for the inpatient hospital stay. This item/service falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. You have been asked to pay a total of $1,080 for the inpatient hospital stay ($360 
copayment x 3 days = $1,080). You have not been charged for the day you were discharged. Therefore, we 
decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on July 16, 
2023, to July 19, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on July 16, 2023, 
to August 18, 2023. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you were unaware the provider 
was OON and didnt know you had 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 $40 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $40 copayment for physical 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 been asked to pay $320 total for 8 physical therapy visits from July 16, 2023 to 
August 18, 2023 ($40 copayment x 8 = $320). Therefore, we decided that the Plan does not have to waive the 
copayment for physical therapy provided on July 16, 2023, to August 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an intraoral x-ray (D0220) provided on 
August 3, 2023. 
 
You asked the Plan to waive the copayment for the dental service. You say that the services should be covered 
as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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. 
 
You have been asked to pay a $15 copayment for an intraoral x-ray. This item/service falls within the Dental 
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 an intraoral x-ray (D0220) 
provided on August 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telehealth evaluation provided on 
August 30, 2023. 
 
You asked the Plan to waive the copayment for the telehealth evaluation. You say that you did not receive this 
services. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for telehealth services. 
 
You have been asked to pay a $25 copayment for the telehealth evaluation. This item/service falls within the 
telehealth 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 telehealth 
evaluation provided on August 30, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breathing capacity test provided on July 18, 2023. 
 
You asked the Plan to pay for the breathing capacity test. 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 breathing capacity 
test provided on July 18, 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 July 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 $42.33 
($84.64 x 50% = $42.32). Therefore, we decided that the Plan does not have to waive the coinsurance for the 
remote monitoring services provided on July 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the debridement procedure provided on 
July 31, 2023. 
 
You asked the Plan to waive the copayment for the debridement procedure. You say that you were expecting a 
$40 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 surgery including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $200 copayment for the debridement procedure. This item/service falls within 
the 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. Therefore, we decided that the Plan 
does not have to waive the copayment for the debridement procedure provided on July 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service and the unlisted dialysis procedure 
provided on July 03, 2023, to July 31, 2023. 
 
You asked the Plan to pay for the laboratory service and the unlisted dialysis procedure. 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 laboratory service 
and the unlisted dialysis procedure provided on July 03, 2023, to July 31, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network acute inpatient stay provided 
on January 23, 2023, to February 08, 2023. 
 
You asked the Plan to waive the copayment for an in-network acute inpatient stay. You say that you should not 
be charged twice just because they had you change which facility you were in. 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 $350 
copayment for inpatient services. 
 
You have been asked to pay a $350 copayment for an in-network acute inpatient stay. This item/service falls within the inpatient 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 been asked to pay a total of $1750 for the inpatient hospital stay ($350 
copayment x 5 days = $1750). You have not been charged for the day you were discharged. Therefore, we 
decided that the Plan does not have to waive the copayment for an in-network acute inpatient stay provided on 
January 23, 2023, to February 08, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
August 31, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. 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 $95 
copayment for emergency care. 
 
You have been asked to pay a $95 copayment for an emergency room (ER) visit. This item/service falls within 
the emergency care benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room 
(ER) visit provided on August 31, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for air ambulance services provided on June 
17, 2023. 
 
You asked the Plan to waive the coinsurance for air ambulance services. You say that you should not be held 
responsible for the coinsurance because you had no choice. 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 in and out-of-network one-way air ambulance services. 
 
You have been asked to pay 50% coinsurance for air ambulance services. This item/service falls within the in 
and out-of-network one-way air ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. The total you owe is $2,234.50 ($4,469.01 allowed amount x 50% 
= $2,234.50). Therefore, we decided that the Plan does not have to waive the coinsurance for air ambulance 
services provided on June 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for in-network chiropractic visits provided on 
June 08, 2023, to July 27, 2023. 
 
You asked the Plan to waive the copayment for in-network chiropractic visits. You say that you should not owe 
these 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). Your contract with the Plan clearly says that you must pay a $20 
copayment for chiropractic services. 
 
You have been asked to pay a $20 copayment for in-network chiropractic visits. This item/service falls within 
the chiropractic 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 total you owe is $40 ($20 copayment x 2 visits = $40). Therefore, we decided that the 
Plan does not have to waive the copayment for in-network chiropractic visits provided on June 08, 2023, to 
July 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an office visit on July 17, 2023. 
 
You asked the Plan to waive the cost share for the office visit. You say that you do not have any of the 
diagnosis listed on your claim and therefore you do not feel that you should be responsible for the charges 
billed to you. 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 $9.55 coinsurance and a $85.93 
deductible. For the service it's $9.55 + $85.93 = $95.48. Therefore, results in the total cost sharing amount of 
$95.48. 
 
You have been asked to pay a $95.48 cost share for the office 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 an office visit on July 17, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on June 
05, 2023, to June 10, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you should not be 
responsible because you were admitted to the facility because of the mistake made by the 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 $295 
copayment for inpatient hospital care.  
You have been asked to pay a $295 copayment for the inpatient hospital stay. This item/service falls within the 
inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. You have been asked to pay a total of $1,475 for the inpatient hospital stay ($295 
copayment x 5 days = $1,475). You have not been charged for the day you were discharged. Therefore, we 
decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on June 05, 
2023, to June 10, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
June 15, 2023. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you cannot afford 
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 $250 
copayment for ambulance services. 
 
You have been asked to pay a $250 copayment for the ambulance transportation. This item/service falls within 
the ambulance services benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
ambulance transportation provided on June 15, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) for the sacroiliac (SI) 
joint (64625). 
 
You asked the Plan to pre-approve the RFA. You say that this is necessary for the enrollee. The Plan denied 
your request. The Plan says this procedure is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that sacroiliac (SI) joint denervation (also called 
radiofrequency ablation or RFA) is not considered reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve 
radiofrequency ablation (RFA) for the sacroiliac (SI) joint (64625).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental service (D4346) on February 27, 2023. 
 
You asked the Plan to pay for the dental service (D4346). You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
service (D4346) on February 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport provided 
on June 8, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment, no transport. You say that you believe the 
right decision was made to call the ambulance because you were unconscious. You say you are on a fixed 
income and cannot afford this bill. The Plan denied your request. The Plan says the service is 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 June 8, 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, no 
transport provided on June 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation and topical application of 
fluoride varnish (D0150, D1206) provided on August 10, 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 comprehensive oral evaluations 
has already been exhausted. Additionally, your dental benefits do not include the topical application of fluoride 
varnish. 
 
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 comprehensive oral evaluations was exhausted on date of service April 20, 2023 
(D0150). Additionally, your dental benefits do not include the topical application of fluoride varnish. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation and topical 
application of fluoride varnish (D0150, D1206) provided on August 10, 2023.