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

 
We decided that the Plan does not have to pay for outpatient services provided on February 4, 2020. 
 
You asked the Plan to pay for the outpatient services. The Plan denied your request. The Plan says the enrollee 
must receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan.  
 
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 
services at issue. 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 outpatient services provided on February 4, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) rendered by the 
out of network (OON) provider on March 3, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was provided by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the psychiatric diagnostic evaluation (90791) rendered by the out of network (OON) provider 
on March 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit services provided to the enrollee on February 14, 
2020. 
 
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 there were network providers available. 
 
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 office visit services provided to the enrollee on 
February 14, 2020.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency care (99284) provided 
September 27, 2019 to September 28, 2019. 
 
You asked the Plan to waive the copayment for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied 
correctly to the service provided. 
 
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 each emergency department visit.  
 
You have been asked to pay a $90 copayment for the emergency care provided. 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 care (99284) provided September 27, 2019 to September 28, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided on September 4, 2019. 
 
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 services were received from a non-Medicare-certified provider. 
 
Medicare rules say that services must be provided by providers who are enrolled in the Medicare program. 
 
You are not eligible to bill Medicare. The Plan did not pre-approve the 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 home health services provided on September 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on December 19, 2019. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented.   
 
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 
laboratory 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 laboratory services provided on December 19, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on April 13, 2020. 
 
You asked the Plan to pay for the psychotherapy 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 
services at issue. 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 psychotherapy services provided on April 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist services provided on April 10, 
2020. 
 
You asked the Plan to waive the copayment for specialist services. You say that you have never been charged 
in the past and disagree with the charges. 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 $20 
copayment per visit to a specialist. 
 
The medical records show that you received specialist services on April 10, 2020. Therefore, you are 
responsible to pay the $20 copayment.   
 
You have been asked to pay a $20 copayment for specialist services. Specialist services fall within the 
physician/practitioner services, including doctor?s 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. Therefore, we decided that the Plan does not have 
to waive the copayment for specialist services provided on April 10, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospice long term care services (code T2046) provided 
from December 1, 2019 to December 31, 2019. 
 
You asked the Plan to pay for the long term care services. You say that when you entered the authorization 
information, it stated that authorization was not required for this service. The Plan denied your request. The 
Plan says the denial of payment for these services is correct, because the billed code is not valid for Medicare 
purposes and is not covered 
 
The Plan must follow Medicare rules. Medicare rules say that procedure code T2046 is not valid for Medicare 
purposes and is not payable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the long term care services have not been met. Therefore, we decided that the Plan does not have to 
pay for the hospice long term care services (code T2046) provided from December 1, 2019 to December 31, 
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for intravenous infusions provided from January 3, 2020 to January 7, 2020.
You asked the Plan to waive the copayments for intravenous infusions. You say that you cannot afford the charges and thought that the services would be covered. 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 outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You received intravenous infusions from January 3, 2020 to January 7, 2020 for a total of 4 services. Therefore, you are responsible to pay the allowed amount of $188.09 which is less than the $250 copayment per each service. The total amount you owe is: $188.09 (copayment) x 4 (services) = $752.36. You have been asked to pay the total copayment amount of $752.36 for intravenous infusions. Intravenous infusions fall within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 copayments for intravenous infusions provided from January 3, 2020 to January 7, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 16, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that the lab performed all the tests that were 
ordered by the referring physician. The Plan denied your request. The Plan says that the Plan requires 
utilization of network providers when possible and available, and requires authorization for certain services. No 
medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been 
documented. 
 
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 and the referring provider are not network providers with the Plan. The Plan 
did not pre-approve the laboratory 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 laboratory services provided on 
December 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis and oral evaluation provided on March 10, 2020.
You asked the Plan to pay for the prophylaxis and oral evaluation. You say that you went to have a problem focused evaluation but received a routine cleaning. The Plan denied your request. The Plan says a prophylaxis and oral exam are covered once every 6 months.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of one cleaning and oral exam every 6 months. The Plan paid for a prophylaxis and oral evaluation on December 3, 2019, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the prophylaxis and oral evaluation provided on March 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on June 6, 2019. 
 
You asked the Plan to pay for drug test. You say that you have submitted a valid order form. The Plan denied 
your request. The Plan says the denial of payment for this service is correct, because the documentation 
submitted does not include a valid physician order, lab requisition, or medical records for the specific test 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician 
order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided 
that Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing provided on June 6, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 28, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the services are an extension of the initial visit. 
The Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers, and 
authorization for certain 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 provider at issue in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue. The Plan did not pre-approve the services at issue. We found 
no exception that would require the Plan to pay for these OON services. Therefore, we decided that the Plan 
does not have to pay for the lab services provided on February 28, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the presumptive and definitive lab testing provided on July 2, 
2019. 
 
You asked the Plan to pay for the drug testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence that the enrollee was ever seen by or treated by the ordering 
provider. As such, this cannot be paid. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing must be ordered by a physician who is 
treating an enrollee for a specific medical problem. 
 
The Plan has indicated that there is no claims history showing that the ordering provider has seen this enrollee. 
No medical records were submitted to support that there is an established relationship between the ordering 
provider and the enrollee for this testing. Therefore, we decided that the Plan does not have to pay for the 
presumptive and definitive lab testing provided on July 2, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee from November 18, 
2019 to December 30, 2019. 
 
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 provider did not include the CLIA number on the submitted claims, or the provider bills 
above their CLIA certification status. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the denied codes are not supported in the medical record. Specifically, a corrected claim is needed 
to show the CLIA number. 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 medical services 
provided to the enrollee from November 18, 2019 to December 30, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic ultrasound (93978) performed on February 21, 2020.
You asked the Plan to waive the copayment for a diagnostic ultrasound. You say that your cost-sharing responsibility is excessive. The Plan denied your request. The Plan says the correct copayment 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 a $160 copayment for each Medicare-covered radiological diagnostic service, not including X-rays. You have been asked to pay a $160 copayment for a diagnostic ultrasound. A diagnostic ultrasound falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a diagnostic ultrasound (93978) performed on February 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 3, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must 
receive care from in-network providers with the exception of emergency or urgent care, or if the care cannot be 
provided with an in-network provider, which requires prior authorization from the plan.  
 
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 
services at issue. 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 March 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance ride provided on January 7, 
2020. 
 
You asked the Plan to waive the copayment for the ambulance ride. You say that you would like the copayment 
waived because you were admitted to the hospital. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing 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 each one-way Medicare-covered ground trip.  
 
You have been asked to pay a $250 copayment for the ambulance ride. The ambulance ride 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 ride provided on January 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray and physician services and 
coinsurance for an injection provided by a participating provider on March 19, 2020. 
 
You asked the Plan to waive the copayment for an x-ray and physician services and coinsurance for an 
injection. You say that you paid your $30 copayment. You say that you do not agree with the additional costs. 
The Plan denied your request. The Plan says the correct copayments and coinsurance have 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 $100 
copayment for other outpatient diagnostic tests/in-network/other outpatient diagnostic tests, a $30 copayment 
for physician/practitioner services/in-network/specialist services, a 20% coinsurance for Medicare Part B 
prescription drugs/in-network.  
 
You have been asked to pay a $100 copayment for an x-ray, a $30 copayment for specialist physician services, 
and a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $1.57. The total 
amount you are being asked to pay for an injection is $0.31. The total amount you are being asked to pay is 
$130.31 ($100 + $30 + $0.31 = $130.31). An x-ray falls within the other outpatient diagnostic tests/in-
network/other outpatient diagnostic tests benefit category.  
 
Physician services falls within the other physician/practitioner services/in-network/specialist services benefit 
category and an injection falls within the other Medicare Part B prescription drugs/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 and coinsurance for an x-ray, physician services, and an 
injection provided by a participating provider on March 19, 2020.