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

 
We decided that the Plan does not have to reduce the copayment from $600 to $200 for the inpatient hospital 
care provided from December 16, 2021, through December 21, 2021. 
 
You asked the Plan to reduce the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
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 $200 per day, for days 1-5 and $0 after day 5, each 
time you are admitted to an acute care hospital. This applies to all admissions, including a transfer from another 
facility such as acute rehabilitation or skilled nursing. 
 
You have been asked to pay $600 ($200 copayment x 3 days) for the inpatient hospital care provided. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to reduce the copayment from $600 to $200 for the inpatient hospital care provided from 
December 16, 2021, through December 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prochlorperazine. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 prochlorperazine.  
 
Benefits for these services 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for durable medical equipment (DME), 
injection services, x-rays, and lab services provided on January 4, 2022. 
 
You asked the Plan to waive the cost-sharing for the DME, injection services, x-rays, and lab 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 enrollees must pay 
a 20% coinsurance for Durable medical equipment (DME) and related supplies, Medicare Part B prescription 
drugs, a $20 copayment (x-rays), and a $5 copayment (Lab) for Outpatient diagnostic tests and therapeutic 
services and supplies.  
 
You have been asked to pay a 20% coinsurance for the DME and injection services ($4,390.14), a $20 
copayment for an x-ray, and a $5 copayment for lab 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 cost-sharing 
for durable medical equipment (DME), injection services, x-rays, and lab services provided on January 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tissue exam provided on November 5, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for tissue exam. 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 tissue exam provided on November 5, 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 copayment for the inpatient mental health care services 
provided from October 18, 2021, through October 22, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
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 $325 
copayment each day, for days 1 to 5 each time you are admitted for inpatient mental health care services.  
 
 You have been asked to pay $1300 ($325 copay x 4 days) for the inpatient mental health care services 
provided. 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 inpatient mental health care services 
provided from October 18, 2021, through October 22, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy service (90834) rendered by the out-of-
network (OON) provider on October 26, 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 psychotherapy service (90834) rendered by the out-of-network (OON) provider on 
October 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids you purchased from an out-of-network provider 
on October 12, 2021. 
 
You asked the Plan to pay for the out-of-network hearing aids. You say that you would like a $500 
reimbursement for the hearing aids you purchased. The Plan denied your request. The Plan says hearing aids 
are not covered when purchased out-of-network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from a network provider.  You did not purchase these hearing aids from a 
network provider. Based on this information, we decided that the Plan's rules for coverage of the out-of-
network hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing 
aids you purchased from an out-of-network provider on October 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 16, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on April 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (74183) 
provided on February 11, 2022. 
 
You asked the Plan to waive the copayment for the MRI. 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 $150 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $150 copayment for the MRI. MRIs 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 
magnetic resonance imaging (74183) provided on February 11, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided 
from January 28, 2022, to February 21, 2022. 
 
You asked the Plan to waive the copayment for the outpatient rehabilitation services. You say that the services 
should be covered as you disagree with the charges. The Plan denied your request. The Plan says the 
coinsurance applied correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 40% 
coinsurance for Outpatient rehabilitation services.  
 
 
  You have been asked to pay a 40% coinsurance for 3 outpatient rehabilitation visits ($228 x 40% = $91.20). 
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 rehabilitation services provided from January 28, 
2022, to February 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses you purchased from an out-of-network provider 
on January 14, 2022. 
 
You asked the Plan to pay for the out-of-network eyeglasses. You say that the provider called the Plan and 
verified that you were covered for these eyeglasses. The Plan denied your request. The Plan says there is no record of you calling to verify this provider's status. The phone call made only verified your eyeglass benefits, 
but the provider's network status was not part of the inquiry. However, the Plan did send you a list of in-
network providers on February 10, 2022. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers eyeglasses when purchased from an in-network provider.  The provider you used is 
not in-network. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses 
you purchased from an out-of-network provider on January 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 28, 2021 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 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 an office visit provided on December 28, 2021 by 
an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Breztri Aerosphere. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 Breztri Aerosphere.  
 
Benefits for these services 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 93000 billed by an outpatient hospital facility on 
January 27, 2022. 
 
You asked the Plan to pay for procedure code 93000. You say that you have had to appeal these charges four 
times and you still haven't been refunded. The Plan denied your request. The Plan says that this claim denied 
because the code billed was not appropriate. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The burden is on the Plan to provide sufficient documentation to support its 
denial.  In this case, the Plan has failed to provide any detail about why the code billed was inappropriate.  The 
Plan has failed to identify what the appropriate code would be.  The Plan has failed to even attempt to get any 
medical records so that we could determine the correct code to be billed. Without any of this information, we 
cannot determine that the Plans denial is supported. Therefore, we decided that the Plan has to pay for 
procedure code 93000 billed by an outpatient hospital facility on January 27, 2022.  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy service (90837) rendered by the out-of-
network (OON) provider on November 24, 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 psychotherapy service (90837) rendered by the out-of-network (OON) provider on 
November 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99310) 
rendered by the out-of-network (OON) provider on August 12, 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 subsequent nursing facility care, per day (99310) rendered by the out-of-network 
(OON) provider on August 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308) 
rendered by the out-of-network (OON) provider on July 8, 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 subsequent nursing facility care, per day (99308) rendered by the out-of-network 
(OON) provider on July 8, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reconsider the cost share for laboratory services provided on February 9, 2022. 
 
You asked the Plan to reconsider the cost share for laboratory services. You say that your doctor's lab tests for 
you every month. The Plan denied your request. The Plan says that 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. Your 
contract with the Plan says that enrollees must pay a $40 copayment for lab services at an outpatient hospital.  
 
The Plan says you must pay a $90 copayment for laboratory services. Based on the Plan contract, however, you 
cannot be asked to pay more than a $40 copayment for laboratory services. Therefore, we decided that the Plan 
has to reconsider the cost share for laboratory services provided on February 9, 2022.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from May 11, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from May 11, 2022, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of inpatient psychiatric care from May 
11, 2022, forward have been met. There are no medical records within the casefile. Without the requested 
clinical information, we are unable to determine if the requested services are medically necessary. Therefore, 
we decided that the Plan does not have to pre-approve inpatient psychiatric care from May 11, 2022, forward.