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

 
We decided that the Plan does not have to pay for psychiatric services (90899) provided from September 3, 
2021, to September 29, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for psychiatric services. You say that you cannot get through to the Plan's in-
network provider for the member's medication, and you have been trying for over a month. You also ask if you 
can stay with this provider. The Plan denied your request. The Plan says the records received do not indicate 
that you have an emergent or urgent medical condition or are in need of specialized services that are not 
available in the network. The Plan also says that there are in-network providers within a reasonable distance 
from your location that can provide this service or item. 
 
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 psychiatric services (90899) provided from 
September 3, 2021, to September 29, 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 a specialist office visit provided on 
September 15, 2021. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that the services should be covered 
as you disagree with the charges and they should have been considered a follow-up visit. 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 $40 
copayment for Physician/Practitioner Services, Including Doctors Office Visits.  
 
 You have been asked to pay a $40 copayment for a specialist visit. Specialist visits fall within the 
Physician/Practitioner Services, Including Doctors Office Visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a specialist office visit provided on September 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on September 1, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the x-ray. You say that the referring physician requested the service so you 
would like the claim reprocessed for payment. The Plan denied your request. The Plan says the rendering and 
referring providers are both out-of-network providers. 
  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 x-ray provided on September 1, 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 December 27, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the referring physician sent the enrollee to you, so 
the service was provided. You would like for the rendered services to be fully reimbursed. The Plan denied 
your request. The Plan says the rendering and referring providers are both out-of-network and there was no 
approved authorization. Also, the service rendered was not urgent or emergent. 
 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 December 27, 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 the office visit (99215) rendered by the out-of-network 
(OON) provider on November 1, 2021. 
 
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 rendered 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 had network providers available 
who could have provided 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 office visit (99215) rendered by the out-of-network (OON) provider on  
November 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 11, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that authorizations are no longer necessary and would 
like the claim to be paid. The Plan denied your request. The Plan says the rendering and referring providers are 
both out-of-network providers and there was no approved authorization. Also, the service rendered was not 
urgent or emergent. 
 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 October 11, 2021, by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the inpatient and home infusion services 
provided from July 6, 2021, to August 8, 2021. 
 
You asked the Plan to waive the cost sharing for the inpatient and home infusion services. You say that you 
should not be responsible, because the need for these services was due to a previous provider's negligence. The 
Plan denied your request. The Plan says the cost sharing applied is correct. 
 
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 the home infusion therapy and a $365 per day copayment for the inpatient hospital care.  
 Date of Service Service Provided Allowed Amount Cost Share per 
Contract 
Your Cost Sharing 
Responsibility 
July 2, 2021  
July 8, 2021 
Inpatient Room and 
Board 
$12,978.58 $365 copay per 
day for days 1-5 
$1,825 
July 9, 2021  
August 6, 2021 
Home Infusion 
Therapy 
$1,769 20% coinsurance $353.80 
July 10, 2021 Specialty Drug 
Administration 
$115 20% coinsurance $23 
July 11, 2021 Specialty Drug 
Administration 
$115 20% coinsurance $23 
July 13, 2021 Specialty Drug 
Administration 
$115 20% coinsurance $23 
July 20, 2021 Specialty Drug 
Administration 
$115 20% coinsurance $23 
July 27, 2021 Specialty Drug 
Administration 
$115 20% coinsurance $23 
August 3, 2021 Specialty Drug 
Administration 
$115 20% coinsurance $23 
August 8, 2021 Specialty Drug 
Administration 
$115 20% coinsurance $23 
Total:    $2,339.80 
 
 
You have been asked to pay $2,339.80 cost sharing for the inpatient and home infusion services. The home 
infusion services fall within the Home infusion therapy benefit category. The inpatient hospital services fall 
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 cost sharing for 
the inpatient and home infusion services provided from July 6, 2021, to August 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on August 9, 
2021. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that you only went for a blood 
test and should not have to pay. 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 $5 per 
day for laboratory tests that are not FIT tests.  
 
You have been asked to pay $5 per day for the laboratory services. The 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 provided on August 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pain management injections to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve pain management injections. You say that these services should be covered 
by the Plan. The Plan denied your request. The Plan says the services have been requested from 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
pain management injections to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Venclexta Tab 100mg. 
 
You asked the Plan to pre-approve Venclexta. You say that the medical records provided support the necessity 
of the services in dispute. The Plan denied your request. The Plan says Venclexta is a self-administered drug 
and does not fall under Part B coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Venclexta Tab 100mg.  
 Benefits for Venclexta may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services provided 
on November 3, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation services. 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 $300 
copayment for Ambulance services.  
 
 
 
  You have been asked to pay a $300 copayment for the ambulance transportation 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 copayment for ambulance transportation services provided on November 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cryoneuroablation (lovera). 
 
You asked the Plan to pre-approve Cryoneuroablation. You say that you are having knee surgery and your 
doctor suggested you have this procedure to reduce pain after surgery and you believe that this should be 
covered. The Plan denied your request. The Plan says Cryoneuroablation (lovera) is considered to be 
investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Cryoneuroablation have not been met. Therefore, we decided that the Plan does not have to pre-
approve Cryoneuroablation (lovera).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 4, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you were unaware that an authorization was needed 
and would like reconsideration of the claim 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. Also, the service 
rendered was not urgent or emergent. 
 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 October 4, 2021, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture services (99203). 
 
You asked the Plan to pre-approve the acupuncture services. You say that the acupuncture services are 
medically necessary. The Plan denied your request. The Plan says this service is not covered for the enrollee's 
diagnosis. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the request is for leg and thigh pain. There is no record of chronic lower back pain. Therefore, we decided that the Plan does not have to pre-approve 
acupuncture services (99203).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a retroperitoneal ultrasound provided on 
October 18, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that abdominal aortic aneurysm 
screenings should be covered. 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 have no 
coinsurance, copayment, or deductible for the screening. This screening is a one-time coverage. 
 
Your contract with the Plan also clearly says that you must pay a $160 copayment for radiological diagnostic 
services, not including X-rays, performed in a physician's office or free-standing facility. 
 
The file shows that your previous ultrasound on October 6, 2020, was reprocessed and paid by the Plan as your 
one-time screening. Any other ultrasounds are subject to the copayment amounts. Therefore, you have been 
asked to pay $132.39 for the ultrasound, which is less than the $160 copayment. The 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 retroperitoneal ultrasound provided on October 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve Eliquis. The Plan denied your request. The Plan says this drug is not eligible 
for coverage under the part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis.  
 
 
 
 Benefits for Eliquis may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (99204) rendered on 
September 15, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that the first time you went, 
you asked if there was a copayment, and nobody said anything. The Plan denied your request. The Plan says 
you were charged the correct copayment 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 $40 
copayment for Medicare-covered specialist visit.  
 
You have been asked to pay a $40 copayment for a specialist office visit. A specialist office visit falls within 
the physician/practitioner services, including doctors office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a specialist office visit (99204) rendered on September 15, 2021.  
 
Your complaint about potentially being billed for services you have already paid 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient rehabilitation services provided 
from May 24, 2021, to June 1, 2021. 
 
You asked the Plan to waive the copayment for the inpatient rehabilitation services. You say that you were an 
inpatient prior to the rehabilitation stay and you should not have another charge. 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 $325 per 
day for days 1-6 and $0 per day for additional days for each inpatient admission. A transfer to a separate 
facility type (such as an Inpatient Rehabilitation Hospital) is considered a new admission.   
The file shows that you were in the rehabilitation hospital from May 24, 2021, to June 1, 2021. Since you had 
transferred from inpatient status, this is considered a new admission. Therefore, you have been asked to pay 
$325 per day for the first 6 days of inpatient rehabilitation services. The total for your stay is $1,950 ($325 
copayment x 6 days = $1,950). The inpatient rehabilitation services fall 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 rehabilitation services 
provided from May 24, 2021, to June 1, 2021.