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

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
July 31, 2021, to August 27, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that the enrollee was 
transferred to a different hospital automatically and without consultation. You also ask why this is not 
considered one continuous hospital stay and covered by the insurance plan. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $450 copayment per day for days 1-4 per admission for an inpatient hospital stay. There is no charge for day 5 and beyond per admission. The Plan contract also says a transfer to a separate facility is 
considered a new admission. 
 
The record shows that a transfer to a separate facility is considered a new admission and the cost sharing 
applies each time you are admitted to the hospital. The enrollee has been asked to pay a total of $1,800, which 
is a $450 copayment per day for the first four days of an inpatient hospital stay ($450 copayment x 4 days = 
$1,800). There is no charge for day 5 and beyond per admission. An inpatient hospital stay falls within the 
Inpatient Hospital Care benefit category. This means that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an 
inpatient hospital stay provided from July 31, 2021, to August 27, 2021.  
 
Your complaint about the enrollee being transferred automatically and without consultation is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lenses provided on December 23, 2021. 
 
You asked the Plan to waive the copayment for the lenses. The Plan denied your request. The Plan says the 
claim paid with the correct copayment. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that there is a $10 copayment for eyewear. Therefore, 
we decided that the Plan does not have to waive the copayment for lenses provided on December 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services (85025, 82043, 82570) 
provided on November 19, 2021. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that the services should be 
covered as you were informed by a representative that the cost would be $0. The Plan denied your request. The 
Plan says the cost-sharing applied correctly based on the services provided, the record indicates that you were 
informed that a physical exam would be $0, the copayment for laboratory services is separate and does apply to 
these services. 
 
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 Outpatient diagnostic tests and therapeutic services and supplies.  
 You have been asked to pay a $20 copayment for laboratory services. Laboratory services fall 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 laboratory services (85025, 82043, 82570) provided on November 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hearing aid check provided on November 24, 2021. 
 
You asked the Plan to pay for a hearing aid check. The Plan denied your request. The Plan says all hearing 
services must be within the Plan's hearing care network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that the hearing services were not provided by a 
provider in the Plans hearing care network. Based on this information, we decided that the Plan's rules for 
coverage of a hearing aid check have not been met. Therefore, we decided that the Plan does not have to pay 
for a hearing aid check provided on November 24, 2021.
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 
December 1, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you feel you should not be 
responsible since your doctor advised you to go. 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 $110 
copayment for each emergency room visit.  
 
 
 You have been asked to pay a $110 copayment for the ER visit. The ER visit 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 December 1, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF admission. You say that you need to be independent and you do not 
have a support system if you were to be released home. The Plan denied your request. The Plan says all the 
services you need are already available at the inpatient rehabilitation facility where you currently are. Transfer 
to a SNF is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you have no identifiable skilled nursing 
needs but you do have skilled therapy needs. However, you do not require skilled therapy on a daily basis in a 
skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0656, 
E0668). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the pneumatic compression 
device is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
The record does not show lymphedema extending onto the chest, trunk and/or abdomen. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652, E0656, E0668).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on December 14, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a home visit. You say that the services should be covered by the Plan. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advance. 
 
 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 had network providers 
available who could have provided 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 a home visit provided on December 14, 2021 by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for an external defibrillator (K0606) provided 
on November 22, 2021. 
 
You asked the Plan to reduce the coinsurance for the external defibrillator. You say that the coinsurance should 
be reduced as you were advised the cost would be cheaper per month. The Plan denied your request. The Plan 
says the coinsurance applied correctly based on the services 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 20% 
coinsurance for Durable Medical Equipment (DME) and Related Supplies.  
 
 
  You have been asked to pay a 20% coinsurance for an external defibrillator (allowed is $2,704.94 x 20% = 
540.99). External defibrillators fall within the Durable Medical Equipment (DME) 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. Therefore, we 
decided that the Plan does not have to reduce the coinsurance for an external defibrillator (K0606) provided on 
November 22, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility services provided on November 1, 
2021 to November 4, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for skilled nursing facility services. You say that the services should be covered by 
the Plan. The Plan denied your request. The Plan says the services were provided out-of-network and were not 
approved in advance. 
 
 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 had network providers 
available who could have provided 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 skilled nursing facility services provided on 
November 1, 2021 to November 4, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Skilled Nursing Facility and Rehabilitation services provided 
on August 27, 2021 to August 31, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Skilled Nursing Facility and Rehabilitation services. You say that you are 
requesting that the claim be reconsidered for payment. The Plan denied your request. The Plan says that Prior 
Authorization is required for skilled nursing facility 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 had network providers 
available who could have provided 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 Skilled Nursing Facility and Rehabilitation 
services provided on August 27, 2021 to August 31, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 3, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you were referred to this provider and the service 
rendered was medically necessary. The Plan denied your request. The Plan says the rendering provider is an 
out-of-network provider and there was no approved 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 had network providers 
available who could have provided 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 an office visit provided on November 3, 2021, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient hospital visit provided on 
October 4, 2021. 
 
You asked the Plan to waive the copayment for the outpatient hospital visit. 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. 
 
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, including services provided at hospital facilities and ambulatory surgical 
centers.  
 
 
  You have been asked to pay a $250 copayment for the outpatient hospital visit. Outpatient hospital visits fall 
within the Outpatient surgery, including services provided at hospital 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 copayment for an outpatient hospital visit 
provided on October 4, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
December 1, 2020, to December 31, 2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the SNF services. You say that you would like the claim to be reprocessed for 
payment. The Plan denied your request. The Plan says the rendering provider is an out-of-network provider and 
there was no approved authorization for the dates of service. 
  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 had network providers 
available who could have provided 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 skilled nursing facility (SNF) services 
provided from December 1, 2020, to December 31, 2020, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Electrocardiogram (ECG) provided on December 20, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Electrocardiogram (ECG). You say that you would like for there to be a change 
of the claim to be an in-network charge rather than out-of-network The Plan denied your request. The Plan says 
prior authorization is required for an out-of-network office visit. 
 
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 had network providers 
available who could have provided 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 Electrocardiogram (ECG) provided on December 
20, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit (99344) and the insertion of temporary 
indwelling bladder catheter (51702) provided on November 4, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a home visit and the insertion of temporary indwelling bladder catheter. You say 
that you provide urgent/emergent care in the home and all places of services, which does not require prior 
authorization per the Center of Medicare/Medicaid Services (CMS) guidelines. The Plan denied your request. 
The Plan says the provider is not contracted with the Plan, and the member does not have out-of-network 
benefits. The Plan also says that there is no documentation that this member was referred to this non-contracted 
provider by a contracted provider, as well as no indication of any attempt made to obtain prior authorization for 
the out-of-network 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 had network providers 
available who could have provided 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 a home visit (99344) and the insertion of 
temporary indwelling bladder catheter (51702) provided on November 4, 2021, by an out-of-network (OON) 
provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided by a network 
facility from October 17, 2021, to October 18, 2021. 
 
You asked the Plan to waive the copayment for the outpatient surgery. You say that you should not owe this 
copayment because you had to have surgery due to complications from a previous surgery. The Plan denied 
your request. The Plan says you have been asked to pay 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 $325 
copayment for surgical service at an in-network outpatient hospital facility.  
 
You have been asked to pay a $325 copayment for outpatient surgery. The outpatient surgery falls within the 
Outpatient surgery, including 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 copayment for outpatient surgery provided 
by a network facility from October 17, 2021, to October 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an eye exam provided on November 17, 
2021. 
 
You asked the Plan to reduce the copayment for the eye exam. You say that your copayment should only be 
$15. 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 $25 
copayment for each specialist office visit for vision services.  
 
You have been asked to pay a $25 copayment for the eye exam. The eye exam falls within the 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. 
Therefore, we decided that the Plan does not have to reduce the copayment for an eye exam provided on 
November 17, 2021.