Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for medical services provided during an 
inpatient stay at an out-of-network facility. 
 
You asked the Plan to waive the coinsurance for the out-of-network medical services. You say that you had no 
idea that the facility or the doctors that you saw there were out-of-network with the plan. The Plan denied your 
request. The Plan says the facility and the doctors you saw there are all out-of-network providers, so you were 
charged this coinsurance 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 (after deductible) for out-of-network inpatient hospital care.  
 
You have been asked to pay 20% coinsurance for the out-of-network medical services. 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 medical services provided during an inpatient stay at an out-of-
network facility.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CMT provided on January 21, 2020 by an OON provider. 
 
You asked the Plan to pay for the CMT. You say that you agreed to the services as long as your insurance 
covered it. You also say that the office contacted your Plan, and was told that you were covered having a $15 
copay. The Plan denied your request. The Plan says the services were rendered by a non-contracted provider. 
The Plan also says that the services were not authorized as required. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. The records show that the Plan contacted the office and confirmed that there was no 
referral on file, and the office did not contact the Plan prior to rendering services. We found no exception that 
would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay 
for the CMT provided on January 21, 2020 by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Botulinum A injections (J0585) received 
on February 27 and May 28, 2020. 
 
You asked the Plan to waive the coinsurance for Botulinum A injections. You say that you cannot afford this 
coinsurance. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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 Medicare Part B covered chemotherapy drugs and other Part B covered drugs.  
 
You have been asked to pay $244.80, or 20% of the Plan-allowed amount of $1,224.00, for date of service 
February 27, 2020, and $244.40, or 20% of the Plan-allowed amount of $1,222.00 for date of service May 28, 
2020. Therefore, you have been asked to pay 20% coinsurance for Botulinum A injections. Botulinum A 
injections fall within the "Medicare Part B prescription drugs" benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for Botulinum A injections (J0585) received on February 27 and May 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on May 20, 
2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges 
because you were transported from the ER to the hospital to be admitted. The Plan denied your request. The 
Plan says the claims were processed correctly and you are being charged the correct amount. 
 
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 ambulance services. Ambulance services fall 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 ambulance services 
provided on May 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chemotherapy administration services provided by an 
OON provider. 
 
You asked the Plan to pay for the chemotherapy administration services. You say that these services do not 
require an authorization. You also say that you believe the denial of payment is an error. The Plan denied your 
request. The Plan says the services were rendered by an OON provider. The Plan also says that the enrollee was 
referred by another non-network provider, and the enrollee's network primary care physician did not refer for 
services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the chemotherapy administration services 
provided by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a 
participating provider on May 28, 2020. 
 
You asked the Plan to waive the copayment for an ambulance trip. You say that you were told that this would 
be paid by the Plan. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 ambulance services.  
 
You have been asked to pay a $200 copayment for an ambulance trip. Since an ambulance trip was provided, 
the correct copayment has been applied. An ambulance trip 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 an ambulance trip provided by a 
participating provider on May 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provide by 
an out of network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that it is the nursing facility staff's responsibility to 
gain any authorization. The Plan denied your request. The Plan says prior authorization must be obtained for 
non-emergent services rendered by an out-of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99309) 
provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the test was performed on a blood specimen performed by venipuncture. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed. 
 
The services at issue in this case were not clearly documented in the case file. The denied codes are for blood 
specimens, but the toxicology request form is for urine specimens Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services provided to the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services you received 
from October 20, 2019, to October 22, 2019. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were never in 
the ICU so you are disputing these charges. The Plan denied your request. The Plan says you were charged this 
copayment correctly. The Plan says that you were in the hospital for two days, so the two-day copayment 
would normally be $450.  However, the Plan says that during this stay you reached your Annual Out of Pocket 
Maximum, which is why you are only being held responsible for $384.03. 
 
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 $225 
copayment per day for days 1-7 for inpatient hospital care.  
 
You have been asked to pay a total of $384.03 because you met your out-of-pocket maximum during this 
hospital stay.  This cost sharing was assessed correctly because you were an inpatient for two days and your 
Evidence of Coverage says that you are charged a $225 per day copayment for inpatient hospital services.  This 
cost sharing applies to all inpatient services, whether or not you are in the ICU.  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 services you received from October 20, 2019, to October 22, 
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 28, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physician?s services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on February 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a 
participating provider on July 7, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you do not feel like the 
services you receive warrant a copayment. The Plan denied your request. The Plan says the correct copayment 
has been applied. 
 
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 $45 
copayment for physician/practitioner services/specialist visit.  
 
You have been asked to pay a $45 copayment for a specialist office visit. Since a specialist office visit was 
provided, the correct copayment has been applied. A specialist office visit falls within the 
physician/practitioner services/specialist 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. Therefore, we decided that the Plan does not have to waive the copayment 
for a specialist office visit provided by a participating provider on July 7, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and coinsurance for lab work provided by an 
out-of-network provider on February 10, 2020. 
 
You asked the Plan to waive the deductible and coinsurance for lab work. You say that you were told this test 
was free. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 $500 
deductible and a 40% coinsurance for outpatient diagnostic tests/lab tests/out-of-network.  
 
You have been asked to pay a $500 deductible and a 40% coinsurance of the allowed amount for lab work. The 
total allowed amount is $7,372.27. The total amount of coinsurance is $2,948.86 ($7,372.27 x 40% = 
$2,948.86). The total amount you are being asked to pay is $3,448.86 ($2,948.86 + $500 = $3,448.86). Lab 
work falls within the outpatient diagnostic tests/lab tests/out-of-network 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 deductible and coinsurance for lab work provided by an out-of-network provider on 
February 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair and related equipment (E0950, E0958, K0004 
K0195) provided on September 16, 2019, by an out of network (OON) provider. 
 
You asked the Plan to pay for the wheelchair equipment and related equipment. You say that you believed prior 
authorization was not required. The Plan denied your request. The Plan says prior authorization was not 
obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the wheelchair and related equipment (E0950, 
E0958, K0004 K0195) provided on September 16, 2019, by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on November 26, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services received were neither emergent 
nor urgent and prior authorization was not obtained to receive out-of-network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the dental services provided on November 26, 
2019 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on March 3, 2020, to 
March 9, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy services. You say that since you received an approval for prior 
services these last two sessions should also be approved. The Plan denied your request. The Plan says prior 
authorization was not obtained by the facility or the provider; therefore, payment has been correctly denied. In 
addition, one-time exceptions were provided as a transition of care to an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the psychotherapy services provided on March 3, 
2020, to March 9, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the emergency room (ER) visit you had on 
April 27, 2020, and the inpatient hospital services you received from April 27, 2020, to May 5, 2020. 
 
You asked the Plan to waive the copayments for the ER visit and inpatient hospital services. You say that you 
cannot afford such a large copayment. The Plan denied your request. The Plan says you were charged these 
copayments 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 emergency room services and a $250 copayment per day for inpatient care, up to a maximum of 
$1500 per admission. 
 
You have been asked to pay a $90 copayment for the ER visit you had and a $1500 copayment for the inpatient 
hospital services. 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 (ER) visit 
you had on April 27, 2020, and the inpatient hospital services you received from April 27, 2020, to May 5, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a skilled nursing stay provided by a 
participating provider on March 18, 2020, to March 31, 2020. 
 
You asked the Plan to waive the copayment for a skilled nursing stay. You say that you should only have a 
copayment for one day. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 $0 
copayment for days 1-20. There is a $160 copayment per day for days 21-100 for skilled nursing facility/in-
network.  
 
You have been asked to pay a $0 copayment for days 1-20. There is a $160 copayment per day for days 21-28 
for a skilled nursing stay. The total amount you are being asked to pay is $1,120 ($160 x 7 days = $1,120). The 
correct copayment has been applied to the skilled nursing stay that was provided. A skilled nursing stay falls 
within the skilled nursing facility/in-network 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 skilled nursing stay provided by a participating provider on March 18, 2020, to March 31, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on October 28, 
2019. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to 
the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on October 5, 2019. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for subsequent nursing 
facility care provided on October 28, 2019.