Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids provided February 18, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for OON hearing aids. You say that you were not aware that the hearing aids would 
not be covered. The Plan denied your request. The Plan says the hearing aids are not covered because you did 
not use the Plan's hearing aid vendor. 
 
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. The Plan pays for 
hearing aids only when purchased through the Plans specified hearing vendor.  
 
We looked at the file and the Plan's rules. In this case the hearing aids were purchased OON. Based on this 
information, we decided that the Plan's rules for coverage of OON hearing aids have not been met. Therefore, 
we decided that the Plan does not have to pay for hearing aids provided February 18, 2022, by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 16, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Gadoterate Meglumine Injection 
provided on February 22, 2022. 
 
You asked the Plan to waive the coinsurance for a Gadoterate Meglumine Injection. You say that you cannot 
understand why this charge is being applied. The Plan denied your request. The Plan says the coinsurance 
applied was 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 20% 
coinsurance for Outpatient Diagnostic Tests and Therapeutic Services and Supplies. The allowed amount of 
this item is $39.60 resulting in a coinsurance amount of $7.92 ($39.60 x 20% = $7.92). 
 
You have been asked to pay a $7.92 coinsurance for a Gadoterate Meglumine Injection. A Gadoterate 
Meglumine Injection 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 coinsurance for a Gadoterate Meglumine 
Injection provided on February 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for supplies for use with an implanted 
ventricular assist device February 17, 2022, and March 21, 2022. 
 
You asked the Plan to waive the coinsurance for supplies. You say that you were not being charged this amount 
for these supplies previously. The Plan denied your request. The Plan says the coinsurance applied was 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a 20% coinsurance for Medicare-covered in-network durable medical equipment (DME) and related 
supplies. The allowed amount of the claim is $1,200, resulting in a coinsurance amount of $240 per date of 
service ($1,200 x 20%). Although the provider is out-of-network, you are being charged the in-network 
coinsurance rate. 
 
The enrollee has been asked to pay $480 for supplies received on two dates of service ($240 x 2). Supplies fall 
within the Durable Medical Equipment (DME) and Related Supplies 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 coinsurance for supplies for use with an implanted ventricular assist device 
February 17, 2022, and March 21, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve targeted case management services (T1017). 
 
You asked the Plan to pre-approve targeted case management services (T1017). You say that the requested 
targeted case management services are medically necessary. The Plan denied your request. The Plan says the 
requested targeted case management services are not medically necessary. 
 
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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of targeted case management services (T1017) have not been met.  
 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 targeted case management services. Therefore, we 
decided that the Plan does not have to pre-approve targeted case management services (T1017).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided on January 12, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network 
and authorization is required prior to 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 outpatient mental health services provided on 
January 12, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided from 
January 1, 2022, to January 8, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you would like the 
copayment lowered that its too expensive. The Plan denied your request. The Plan says the copayment 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 $350 
copayment per day for days 1through 5 and $0 after day 5.  
 
You have been asked to pay $1,750 ($350 x 5 days) copayment for inpatient hospital stay. Inpatient hospital 
stay falls 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 hospital stay provided from January 1, 2022, to January 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on March 7, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you never stayed overnight so 
you shouldn't have to pay this much. The Plan denied your request. The Plan says the copayment 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 $295 
copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, 
including but not limited to hospital or other facility charges and physician or surgical charges.  
 
 
 
 You have been asked to pay $295 copayment for outpatient surgery. Outpatient surgery falls 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 copayment for outpatient surgery 
provided on March 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 9, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to 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 an office visit provided on February 9, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided March 9, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the OON hearing aids. You say that your provider can provide ongoing support 
and maintenance for your hearing aids. The Plan denied your request. The Plan says the hearing aids are not 
covered because they were provided OON. 
 
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. The Plan pays for 
hearing aids only when you obtain prior authorization and use a network provider. 
 
We looked at the file and the Plan's rules. In this case the hearing aids were purchased OON without prior 
authorization. Based on this information, we decided that the Plan's rules for coverage of the OON hearing aids 
have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids provided 
March 9, 2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for physical therapy visits provided from March 
3, 2022, to March 31, 2022. 
 
You asked the Plan to waive the cost share for physical therapy visits. You say that you thought you met your 
deductible already and you cannot afford these charges. The Plan denied your request. The Plan says the cost 
share applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $500 deductible which applies to Outpatient Rehabilitation Services 
and a $5 copayment for each physical therapy visit.  
 
 
 
 
 The item or service you asked the Plan to waive the cost share for falls within the benefit category Outpatient 
Rehabilitation Services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is 
$500 deductible which applies to Outpatient Rehabilitation Services. This cost sharing is a contractual 
obligation that had not been met at the time physical therapy visits was received on March 3, 2022, to March 
31, 2022. Therefore, $254.47 has been applied to meet the deductible.  
 
Since the $500 deductible was met, you have also been asked to pay $5 copayment for each physical therapy 
visits 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 the Plan does not have to waive the cost for physical therapy provided on March 3, 2022, to March 31, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME provided on March 4, 2022. 
 
You asked the Plan to waive the coinsurance for DME. You say that this should be covered under the surgery 
cost since its associated with that. The Plan denied your request. The Plan says the coinsurance 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 Medicare-covered benefits.  
 
You have been asked to pay $540.99 which is 20% of the allowed amount for DME. The allowed amount is 
$2,704.94 (20% x $2,704.94 = $540.99). DME falls 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 waive the coinsurance for DME provided on 
March 4, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Part B drugs provided on November 2, 
2020. 
 
You asked the Plan to waive the coinsurance for Part B drugs. You say that this has always been covered in the 
past, so you dont know why you must pay now. The Plan denied your request. The Plan says the coinsurance 
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 Medicare-covered Part B drugs dispensed at a retail pharmacy, mail order pharmacy, physician 
office, and outpatient facility.  
 
 
 
 You have been asked to pay $411.18 which is 20% of the allowed amount for Part B drugs.  The allowed 
amount is $2,055.88 (20% x $2,055.88 = $411.18). Part B drugs falls within the Medicare Part B Prescription 
Drugs benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the coinsurance for Part B drugs provided on 
November 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided from 
February 18, 2022, to February 21, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you were misdiagnosed so 
it should be covered. The Plan denied your request. The Plan says the copayment 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 $390 
copayment each day in a hospital for the first five days; you pay $0 for each day after day 5 for each inpatient 
stay.  
 
 
 
 You have been asked to pay $1,170 ($390 x 3 days) copayment for inpatient hospital stay. Inpatient hospital 
stay falls 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 hospital stay provided from February 18, 2022, to February 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections provided on January 3, 2022. 
 
You asked the Plan to waive the coinsurance for injections. You say that this amount is wrong and should be 
reprocessed. The Plan denied your request. The Plan says the coinsurance 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). The enrollees contract with the Plan clearly says that enrollees 
must pay 20% coinsurance for Medicare covered Part B drugs.  
 
The enrollee has been asked to pay $346.13 which is 20% of the allowed amount for injections. The allowed 
amount is $1,730.63 (20% x $1,730.63= $346.13). Injections fall within the Medicare Part B Prescription 
Drugs 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 coinsurance for injections provided on 
January 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 18, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 7, 2022, and infrared 
therapy provided on February 10, 2022. 
 
You asked the Plan to pay for the office visit and infrared therapy. You say that you were misinformed and 
wish to see this provider again. You say that you want to know why these were denied. The Plan denied your 
request. The Plan says these services are not covered when billed by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided on February 7, 2022, and infrared therapy provided 
on February 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the requested Intracept procedure is 
medically necessary. The Plan denied your request. The Plan says the requested Intracept procedure is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 an Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not medically necessary. Our physician reviewer found the 
Intracept procedure is experimental. More research is needed. At this time, the procedure is not medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on April 5, 
2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you should not have to pay 
this since the visit was with the physician assistant and not the doctor. The Plan denied your request. The Plan 
says the copayment 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 $45 
copayment for physician specialist services (including surgery second opinion, telehealth services, home 
infusion professional services, and urgently needed services).  
 
 
 
 You have been asked to pay $45 copayment for specialist office visit. Specialist office 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 specialist office visit provided on April 5, 2022.