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

 
We decided that the Plan does not have to pay for Specialist office visit provided on December 22, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Specialist office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider that referred the services is OON and it was 
determined these services were 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 Specialist office visit provided on December 22, 
2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on November 
24, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you are unable to afford the 
ambulance charges. The Plan denied your request. The Plan says the copayment applied 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 $300 
copayment for each covered, one-way ambulance trip by ground or water.  
 
You have been asked to pay $300 for the 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 the ambulance services 
provided on November 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for otolaryngology telehealth specialist visits 
provided on November 11, 2021, and November 22, 2021. 
 
You asked the Plan to waive the copayments for telehealth specialist visits. You say that you should not have to 
pay a copayment for an unscheduled phone call from the doctor. 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 $30 
copayment for each telehealth specialist visit.  
 
The medical records show you had a telehealth visit with the provider on November 11, 2021, and November 
22, 2021. You have been asked to pay a $30 copayment for each telehealth specialist visit. A telehealth specialist visit falls 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 copayments for otolaryngology telehealth specialist visits 
provided on November 11, 2021, and November 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) rendered by the 
out-of-network (OON) provider on January 10, 2022. 
 
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 hospital outpatient clinic visit (G0463) rendered by the out-of-network (OON) 
provider on January 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (88305) rendered by the out-of-
network (OON) provider on December 14, 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 laboratory service (88305) rendered by the out-of-network (OON) provider on 
December 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services 
provided from December 1, 2021 to December 22, 2021. 
 
You asked the Plan to waive the copayment for the SNF stay. 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 $184 
copayment per day for days 21-100 for Skilled nursing facility (SNF) care.  
 
 
  You have been asked to pay a $3,156.36 copayment for days 21-42 of the SNF stay, this is less than the 
standard $184 copayment per day. 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 skilled nursing 
facility (SNF) services provided from December 1, 2021, to December 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on December 2, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for lab testing. You say that these services were ordered by the enrollee's physician. 
The Plan denied your request. The Plan says the denial of payment for this service is correct, because this 
provider is out-of-network with the Plan and the ordering physician was also out-of-network with 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 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 lab testing provided on December 2, 2021 by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan 
(75574) provided on November 12, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. 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 $75-
300 copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 You have been asked to pay a $114.11 copayment for the CT scan. CT scans 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 the computed tomography (CT) scan (75574) provided on November 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says care could be received in another setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on September 4, 2021. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you were 
stabilized at home after treatment, and you did not need to be transported to the hospital. You say that you were 
trying to save the health Plan money by not going to the hospital. The Plan denied your request. The Plan says 
the transport of a Medicare beneficiary must occur for an ambulance transport to be payable under the 
Medicare Program. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 4, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
(A0998) provided on September 4, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a doppler echocardiograph provided on 
December 7, 2021. 
 
You asked the Plan to waive the copayment for a doppler echocardiograph. You say that you were not aware of 
the copayment at the time of service. You also say that when you had an EEG performed previously on your 
foot the provider's office told her upfront that $150 was needed. 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 $150 
copayment for outpatient diagnostic testing.  
 
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$150 copayment for a doppler echocardiograph. A doppler echocardiograph 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 doppler echocardiograph provided on December 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) 
provided on July 12, 2021. 
 
You asked the Plan to waive the copayment for an MRI. You say that you are not responsible for this charge. 
The Plan denied your request. The Plan says the copayment amount charged 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 a $200 
copayment for each advanced imaging service (e.g; MRI, CT and PET scans, nuclear medicine, and stress 
tests).  
 
You have been asked to pay a $200 copayment for an MRI. An MRI 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 magnetic resonance imaging (MRI) provided on July 12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for mental health telehealth visits provided 
from January 20, 2022, to February 9, 2022. 
 
You asked the Plan to waive the copayments for mental health telehealth visits. You say that you thought you 
had six free counseling sessions but received a bill for them. 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 $30 
copayment for each telehealth outpatient mental health visit. The Plan contract also says that enrollees must 
pay a $0 copayment for six caregiver counseling session per year, when scheduled through the Plan. 
 
According to the EOC, appointments need to be scheduled through the Plan to qualify for the six free 
counseling sessions. The Plan confirmed you did not schedule the mental health telehealth visit through the 
Plan. You have been asked to pay a $30 copayment for each mental health telehealth visit on January 20, 2022, 
January 27, 2022, February 3, 2022, and February 9, 2022. Mental health telehealth visits fall within the 
Outpatient Mental Health 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 copayments for 
mental health telehealth visits provided from January 20, 2022, to February 9, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the stress test provided on October 8, 2021. 
 
You asked the Plan to waive the copayment for a stress test. You say that you believe theres been a 
misinterpretation and a stretch of written coverage in the Plans EOC. The Plan denied your request. The Plan 
says that per the EOC, the cost applied 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 does not say in clear and accurate terms 
the specific copayment you should expect to pay for diagnostic radiology services.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $300 
copayment for stress tests. The Plan contract only lists a copayment range and does not clearly disclose the 
specific copayment enrollees should expect to pay for each diagnostic radiology service. This means that the 
Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the 
Plan has to waive the cost for the stress tests provided on October 8, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomographic angiography 
(CTA) of coronary arteries provided on November 12, 2021. 
 
You asked the Plan to waive the copayment for a CTA. You say that you have had problems getting issues 
resolved with the insurance companys customer service. 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 $75-
$300 copayment for diagnostic radiology services, including CTAs.  
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
the allowed amount of $172.20, which is less than the $300 copayment for a CTA. A CTA 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 computed tomographic angiography (CTA) of coronary arteries provided on 
November 12, 2021.  
 
Your complaint about the customer service 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency care visit (ER) provided on 
November 5, 2021. 
 
You asked the Plan to waive the copayment for the ER 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 $110 
copayment for Emergency care.  
 
 You have been asked to pay a $110 copayment for the ER visit. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for an emergency care visit (ER) provided on November 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Ophthalmological Services provided on January 6, 2022 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for Ophthalmological Services. You say that that it isn't your responsibility to obtain 
prior authorization. The Plan denied your request. The Plan says prior authorization is required for an out-of-
network 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 Ophthalmological Services provided on January 6, 
2022 by an out-of-network (OON) provider.