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

 
We decided that the Plan does not have to waive the cost share for the office visit and injection provided on 
January 26, 2022. 
  You asked the Plan to waive the cost share for the office visit and injection. You say that there should be no 
cost share for injections under the skin in the doctors office. The Plan denied your request. The Plan says the 
cost share was 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 20% 
coinsurance for each Medicare-covered Part B drug and non-chemotherapy drugs to treat cancer. Your contract 
with the Plan also clearly says that enrollees must pay a $10 copayment for services obtained from a primary 
care provider or under certain circumstances, treatment by a nurse practitioner or physicians assistant or other 
non-physician health care professionals in a primary care providers office (as permitted under Medicare rules). 
 
You have been asked to pay a total of $10.42 for the office visit and injection.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
January 26, 2022 Office Visit $14.42 $10 Copayment $10 
January 26, 2022 Injection $2.12 20% Coinsurance $0.42 
TOTAL:    $10.42 
 
The office visit falls within the Physician/Practitioner Services, Including Doctors Office Visits benefit 
category. The injection falls under 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 cost share for the office visit and injection provided on January 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (80050, 80061, 82306) rendered by 
the out-of-network (OON) provider on December 3, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the laboratory services (80050, 80061, 82306) rendered by the out-of-network 
(OON) provider on December 3, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility services provided on December 6, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for skilled nursing facility services. You say that it is the hospital's responsibility to 
obtain authorization for the services. 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 
December 6, 2021 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 ambulance services (A0427, A0425) provided on 
December 9, 2019. 
 
You asked the Plan to pay for ambulance services. You say that this claim was submitted once and should be 
paid. The Plan denied your request. The Plan says the enrollee had another insurance listed as their primary 
carrier on the date in question. This claim cannot be paid by this Plan until an explanation of benefits from the 
primary insurer is provided. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to bill the primary insurer. As the secondary insurer, the Plan cannot be held responsible for 
ambulance services until the primary insurer has denied the claim for these services. Therefore, we decided that 
the Plan does not have to pay for the ambulance services (A0427, A0425) provided on December 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Trionic all-terrain walker rendered on October 11, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the Trionic all-terrain walker rendered on October 11, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility services provided to the enrollee on 
September 14, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or 
unrelated to the members terminal condition 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.  Therefore, we decided that the Plan does not have to pay for nursing facility services provided to the enrollee 
on September 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hyperbaric oxygen therapy provided to the enrollee on 
November 12, 2021. 
 
You asked the Plan to pay for the therapy. You say that this should be paid for. The Plan denied your request. 
The Plan says traumatic brain injury is not a covered diagnosis for hyperbaric oxygen therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that hyperbaric oxygen therapy is covered for specific 
indications. 
 
Traumatic brain injury is not listed as a covered indication for this therapy in the applicable guidelines. Based 
on this information, we decided that Medicare rules for coverage of the therapy have not been met. Therefore, 
we decided that the Plan does not have to pay for hyperbaric oxygen therapy provided to the enrollee on 
November 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Medication assisted treatment, methadone provided on 
September 27, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Medication assisted treatment, methadone. You say that you would like to 
request reconsideration for payment. 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 Medication assisted treatment, methadone 
provided on September 27, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH admission is 
medically necessary. The Plan denied your request. The Plan says the requested LTACH admission is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 the LTACH services. Our reviewer says 
that the requested LTACH admission is not medically necessary. Our physician reviewer found the enrollee 
was admitted with acute kidney injury after being found down at home unresponsive after a recent stroke. The 
record indicates that the enrollee is improving but still requires ongoing acute care services before transitioning 
to a lower level of care.    The enrollee continues to receive acute care services, and these have not been denied. 
The medical record does not indicate that the enrollee requires services that he is not currently receiving but 
that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The 
requested service cannot be recommended. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
January 1, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you should not have 
an ambulance copayment since you were admitted to the hospital. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $240 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $240 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance Services benefit category. Please note that this benefit does not include a cost share 
waiver due to hospital admission. 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 provided on January 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an aflibercept injection provided on 
September 21, 2021. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you disagree with the 20% 
coinsurance. 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 20% 
coinsurance for Part B drugs.  
 
You have been asked to pay $367.55, which is 20% coinsurance of the allowed amount for an injection 
($1,837.74 allowed amount x 20% coinsurance = $367.55). An injection 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 an aflibercept 
injection provided on September 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay from April 9, 2021, 
through April 12, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that your stay was COVID-19 
related so you should not be billed. You say that you are on a fixed income and find the cost out of your 
comfort zone. The Plan denied your request. The Plan says coinsurance 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 $345 
copayment for each Medicare-covered day, for days 1-5 and a $0 copayment for each additional day for 
inpatient stay.  
 
  You have been asked to pay $1035 for the inpatient hospital stay ($345/day x 3 days = $1035). The 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 from April 9, 2021, through April 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services (97810, 97811) provided November 5, 
2021. 
 
You asked the Plan to pay for the acupuncture services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that treatments may be provided by a physician in 
accordance with state requirements, or by physician assistants, nurse practitioners/clinical nurse specialists, and 
auxiliary personnel if they meet certain licensure requirements. Auxiliary personnel furnishing acupuncture 
must be under the appropriate level of supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist. 
 
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 service was not performed by a physician or 
under the supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist. 
Therefore, we decided that the Plan does not have to pay for acupuncture services (97810, 97811) provided 
November 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ophthalmology services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve Ophthalmology services. You say that you would like to appeal the denial 
of the claim. The Plan denied your request. The Plan says the provider is now out-of-network and it was 
determined these services can be received in-network. 
 
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 
Ophthalmology services to be provided 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 a pain specialist office visit provided on 
February 21, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you were told you would 
receive free trials before the insurance was billed. You also say you never went back due to the experience of 
the injections and was never told about the $50 copayment. 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 $50 
copayment for a specialist office visit.  
 
The Plan confirmed the procedure was not free of charge but a trial to see if the injections alleviated your pain. 
You have been asked to pay a $50 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 pain specialist office visit provided on February 21, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy performed on 
February 17, 2022. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that the procedure was done to stop 
bleeding from a routine colonoscopy the day before. You say that you should not be responsible for this error. 
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 $350 
copayment for each surgery or service provided at an outpatient hospital facility.  
 
You have been asked to pay a $350 copayment for the colonoscopy. The colonoscopy 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 a diagnostic colonoscopy 
performed on February 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 17, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for [Shorter description of ITEM or SERVICE at issue, e.g. "a power wheelchair"]. 
You say that the services provided were urgent. 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 August 17, 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 CT scan and x-ray provided on 
December 14, 2021. 
 
You asked the Plan to waive the copayment for the CT scan and x-ray. You say that the tests are required while 
Federal Emergency in in place until further notice. The Plan denied your request. The Plan says the copayment 
was 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 $210 
copayment for other Medicare-covered diagnostic radiology services (not including x-rays) and a $25 
copayment for Medicare-covered x-rays.  
 
 
  You have been asked to pay a total of $235 ($210 for the CT scan and $25 for the x-ray) for the CT scan and x-
ray. The CT scan and x-ray both 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 CT scan and x-ray 
provided on December 14, 2021.