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

 
We decided that the Plan does not have to waive the copayments for the emergency room visit, and inpatient 
hospital stay provided from January 4, 2023, to January 10, 2023. 
 
You asked the Plan to waive the copayments for the emergency room visit, and inpatient hospital stay. You say 
that you were told when signing up for the Plan that these services would be covered. 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 each emergency room visit. Your contract with the Plan also clearly says that you must pay a 
$250 copayment per day for days 1-7 of each inpatient hospital stay. 
 
You have been asked to pay a $95 copayment for the emergency room visit. This item/service falls within the 
emergency care benefit category. You have also been asked to pay a $250 copayment per day for days 1-6 of 
the inpatient hospital stay. You have not been charged after day six or for the day you were discharged. You 
have been asked to pay a total of $1,500 for the inpatient hospital stay ($250 copayment per day x 6 days = 
$1,500). 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 copayments for the emergency room visit, and inpatient 
hospital stay provided from January 4, 2023, to January 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided on August 05, 2022. 
 
You asked the Plan to pay for injections. 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 injections provided on 
August 05, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on January 10, 2023. 
 
You asked the Plan to pay for laboratory testing. 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 laboratory testing 
provided on January 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on December 28, 2022. 
 
You asked the Plan to pay for a nursing facility visit. You say that we depend upon the facility staff to verify 
eligibility and to obtain 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 a nursing facility visit 
provided on December 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray and panoramic radiographic image 
(D0210, D0330) provided on September 21, 2022. 
 
 
You asked the Plan to pay for the dental service. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
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 an 
intraoral x-ray and panoramic radiographic image (D0210, D0330) provided on September 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the podiatry services provided on January 
11, 2023. 
 
You asked the Plan to waive the copayment for the podiatry services. You say that you have never had a 
copayment for these services 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 $15 
copayment for podiatry services. 
 
You have been asked to pay a $15 copayment for the podiatry services. This item/service falls within the 
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 services 
provided on January 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the home ventilator provided on August 
25, 2022. 
 
You asked the Plan to waive the coinsurance for the home ventilator. You say that you tried several times to 
return this equipment. 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 10% 
coinsurance for durable medical equipment and related supplies. 
 
You have been asked to pay 10% coinsurance for the home ventilator. 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. The record shows this claim was approved and you are responsible for the 
cost share amount. The total you owe is $105.52 ($1,055.23 allowed amount  x 10% coinsurance = $105.52). 
Therefore, we decided that the Plan does not have to waive the coinsurance for the home ventilator provided on 
August 25, 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 
(A0998) provided on January 2, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you called 
the nurse line with your symptoms and were advised to call 911. You also say that you were told your vitals 
were in range and you could choose to stay and call them back if needed. The Plan denied your request. The 
Plan says the ambulance did not transport you, therefore, the claim denied correctly. The Plan also says that 
you are responsible for the entire cost of the non-transport ambulance services since an ambulance was 
dispatched, but transportation did not take place. 
 
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 2, 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 (A0998) provided on January 2, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hand x-rays provided on February 15, 2023. 
 
You asked the Plan to pay for hand x-rays. 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 hand x-rays provided on 
February 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental filling (D2335) provided on December 13, 2022. 
 
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 the services denied correctly as they do not fall 
within your dental benefits. 
 
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 a dental 
filling (D2335) provided on December 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on July 18, 
2022, to July 23, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are disputing the share 
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 $390 
copayment for days 1 to 5 for Inpatient Hospital Care. This inpatient hospital stay lasted 5 days, resulting in a 
copayment amount of $1950 ($390 per day for 5 days = $1950). 
 
You have been asked to pay $390 copayment for days 1 to 5 for inpatient hospital care. 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. Therefore, we decided that the Plan does not have to waive the copayment for 
inpatient hospital care provided on July 18, 2022, to July 23, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency care visit provided on 
September 25, 2022. 
 
You asked the Plan to waive the copayment for an emergency care visit. You say that you are disputing the 
share 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 Emergency care. 
 
You have been asked to pay a $50 copayment for an emergency care 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 care 
visit provided on September 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that this hospital bed is extremely 
necessary for your health condition.  The features on this bed are not just for convenience. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the ambulance services provided on 
October 8, 2022. 
 
You asked the Plan to waive the deductible for the ambulance services. You say that you could not find an in-
network ambulance during an emergency. 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 $1,000 deductible which applies to out-of-network ambulance 
services. Your contract with the Plan also says that you must pay a $270 copayment after meeting the 
deductible for in-network or out-of-network ambulance services. 
 You have been asked to pay $511.21 towards the deductible. The item or service you asked the Plan to waive 
the deductible for falls within the ambulance services benefit category. The Plan has followed Medicare rules 
by clearly disclosing in the contract that there is a $1,000 deductible which applies to out-of-network 
ambulance services. This cost sharing is a contractual obligation that had not been met at the time the 
ambulance services was received on October 8, 2022. Therefore, we decided that the Plan does not have to 
waive the deductible for the ambulance services provided on October 8, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
December 21, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that this cost is too high for 
how far the ambulance had to go. 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 ground ambulance services. 
 
You have been asked to pay a $250 copayment for the ambulance services. This item/service falls within the 
ground 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 services provided on December 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote patient monitoring services provided on October 15, 
2022. 
 
You asked the Plan to pay for remote patient monitoring services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for remote patient 
monitoring services provided on October 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the drug administration provided on 
October 19, 2022. 
 
You asked the Plan to waive the copayment for the drug administration. You say that this service was paid for 
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 in-network primary care physician/practitioner services. 
 
You have been asked to pay a $25 copayment for the drug administration. This item/service falls within the in-
network primary care 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. The record shows this claim was approved and you are 
responsible for the cost share amount. However, since the allowed amount is less than the standard copayment, 
you only owe $14.48. Therefore, we decided that the Plan does not have to waive the copayment for the drug 
administration provided on October 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for each eye exam provided on October 06, 
2022, to December 02, 2022. 
 
You asked the Plan to reduce the copayment for each eye exam. You say that you should only have to pay $10 
for an in-network 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 $20 
copayment for in-network vision care. 
 
You have been asked to pay a $20 copayment for each eye exam. This item/service falls within the in-network 
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. The total amount you owe is $60 ($20 copayment x 3 exams = $60). Therefore, we decided that the Plan 
does not have to reduce the copayment for each eye exam provided on October 06, 2022, to December 02, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the spinal nerve procedure provided on 
January 09, 2023. 
 
You asked the Plan to waive the copayment for the spinal nerve procedure. You say that you thought this was 
fully covered by the Plan. 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 $370 
copayment for outpatient surgery provided by an outpatient hospital. 
 
You have been asked to pay a $370 copayment for the spinal nerve procedure. This item/service falls within the 
outpatient surgery provided by an outpatient hospital 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 spinal nerve procedure provided on January 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for care planning provided on December 01, 2022. 
 
You asked the Plan to pay for care planning. 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 care planning provided 
on December 01, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) and a core buildup (D2950) provided on 
January 30, 2023. 
 
You asked the Plan to pay for a crown and a core buildup. You say that you thought this would be covered. The 
Plan denied your request. The Plan says single crowns are not covered without previous root canal treatment.  
 
 
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.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a crown and a core buildup have not been met. Therefore, we decided that the Plan does not have 
to pay for a crown (D2740) and a core buildup (D2950) provided on January 30, 2023.