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

 
We decided that the Plan does not have to pay for the therapy services provided on November 1, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the therapy services. You say that there was an approved authorization for the 
enrollee to receive services and prior visits were paid. The Plan denied your request. The Plan says the 
rendering provider is an out-of-network provider and for the date of service the billed claim exceeded the 
authorization. Also, the service rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the therapy services provided on November 1, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tissue exam by pathologist provided on November 11, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a tissue exam by pathologist. You say that although no authorization was 
obtained, you believe the services were medically necessary. The Plan denied your request. The Plan says this 
provider is not a network provider with the Plan and the services were not referred by a network provider or 
rendered in an in-network facility. The Plan also says that they have also determined that these services are not 
urgent or emergent, nor were they 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 a tissue exam by pathologist provided on 
November 11, 2021, 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 an outpatient hospital observation stay 
provided from December 12, 2021, to December 17, 2021. 
 
You asked the Plan to waive the copayment for an outpatient observation stay. You say that you do not 
understand why you are being charged for separate services. 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 $225 
copayment for an outpatient hospital observation stay.  
 
The record shows the claim was reprocessed to reflect an outpatient hospital observation stay, which has a cost 
sharing amount. You have been asked to pay a $225 copayment for an outpatient observation stay. An outpatient observation stay falls within the Outpatient Hospital Observation 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 an outpatient hospital observation stay provided from December 12, 
2021, to December 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a magnetic resonance imaging (MRI) of 
the spine, an ultrasound, and a hysterectomy performed from August 26, 2021, to November 23, 2021. 
 You asked the Plan to waive the copayments for the MRI, ultrasound, and hysterectomy. You say that the 
benefits booklet is not clear on what copayments apply for the services provided. 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 $250 
copayment for advanced imaging services at an outpatient hospital, such as MRI's. 
 
Your contract with the Plan also clearly says that you must pay a $100 copayment for diagnostic procedures 
and tests at an outpatient hospital, such as ultrasounds. 
 
Your contract with the Plan also clearly says that you must pay a $250 copayment for surgery performed at an 
outpatient hospital. 
 
You have been asked to pay a $250 copayment for the MRI. You have also been asked to pay a $100 
copayment for the ultrasound. The MRI and ultrasound fall within the Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies benefit category. You have also been asked to pay a $250 copayment for the 
hysterectomy. The hysterectomy falls within the Outpatient Surgery, Including Services Provided at Hospital 
Outpatient Facilities and Ambulatory Surgical Centers benefit category. The total for all three services is $600. 
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 a magnetic resonance imaging (MRI) of the spine, an 
ultrasound, and a hysterectomy performed from August 26, 2021, to November 23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for physical therapy (PT) services provided 
from October 15, 2021, to November 1, 2021. 
 
You asked the Plan to waive the deductible for the PT services. You say that the charges should not apply to 
your deductible. The Plan denied your request. The Plan says the correct amount was applied to your 
deductible. 
 
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 $750 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Outpatient Rehabilitation 
Services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is $750 deductible which applies to certain items and services. This cost sharing is a contractual obligation that 
had not been met at the time the PT services were received from October 15, 2021, to November 1, 2021. 
Therefore, we decided that the Plan does not have to waive the deductible for physical therapy (PT) services 
provided from October 15, 2021, to November 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a hospital outpatient clinic visit provided 
on January 10, 2022. 
 
You asked the Plan to waive the copayment for a hospital outpatient clinic visit. You say that you do not feel 
you should have to pay a copayment because it was not a doctor it was a nurse that you were seen by. You also 
say that you do not care what kind of training the nurse has, you thought that everything was supposed to be 
covered. The Plan denied your request. The Plan says you were 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 $35 
copayment for each telehealth specialist visit.  
 
You have been asked to pay a $35 copayment for a hospital outpatient clinic visit. A hospital outpatient clinic 
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 hospital outpatient clinic visit provided on January 10, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the CPAP machine provided on October 2, 
2021. 
 
You asked the Plan to waive the coinsurance for the CPAP machine. You say that you purchased the CPAP 
machine and should not be charged a rental fee. The Plan denied your request. The Plan says the coinsurance 
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 item. The allowed amount of the CPAP machine totaled $39.70, 
resulting in a total coinsurance amount of $7.94. 
 
You have been asked to pay 20% coinsurance for the CPAP machine. CPAP machines fall 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 the CPAP machine provided on October 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on October 30, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. 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 the office visit provided on October 30, 2021 by 
an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
November 20, 2021. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you made multiple attempts to seek 
services at urgent care locations but were unable due to COVID-19 protocols and office's being closed. 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 $90 
copayment for an emergency room visit.  
 
You have been asked to pay a $90 copayment for an ER visit. An ER visit falls within the Emergency 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 an emergency room (ER) visit 
provided on November 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
December 22, 2021. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that there was no doctor involved 
during the check. 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 $40 
copayment for specialist office visits.  
 
You have been asked to pay a $40 copayment for the specialist visit. The 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 copayment for a specialist office visit provided on December 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgery and lab services 
provided on February 10, 2022. 
 
You asked the Plan to waive the copayment for the outpatient surgery and lab services. You say that you've had 
the same surgery done before and you never had to pay. The Plan denied your request. The Plan says the 
copayments 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 $195 
copayment for the outpatient surgery and a $30 copayment for the lab services.  
 
You have been asked to pay a total of $225 (a $195 copayment for outpatient surgery and a $30 copayment for 
lab services). Outpatient surgery falls within the Outpatient hospital services benefit category. The lab 
services fall within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the outpatient surgery and lab services provided on February 
10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 3, 2021 by an 
out-of-network (OON) provider. 
 
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 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 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 the laboratory services provided on December 3, 
2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 
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 the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Gelsyn-3.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services rendered on July 3, 2019. 
 
You asked the Plan to pay for these services. You say that your in-network gastroenterologist ordered the 
testing. The Plan denied your request. The Plan says that the services were rendered by an out-of-network 
provider without prior authorization. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for these services by a contract provider. The file does not show that the Plan provided 
notice that these services would not be covered. Under Medicare rules, this means these services is considered 
approved by the Plan. Therefore, we decided that the Plan has to pay for the laboratory services rendered on 
July 3, 2019.  
 
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 Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises and activities, and gait training 
provided on January 11, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for therapeutic exercises and activities, and gait training. You say that you would 
like reconsideration stating the provider referral is submitted. The Plan denied your request. The Plan says this 
provider is not a network provider with the Plan, and they have also determined that these services are not 
urgent or emergent, nor were they 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 therapeutic exercises and activities, and gait 
training provided on January 11, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for a magnetic resonance 
imaging (MRI) of the pelvis and a gadobutrol (contrast agent) injection provided on February 2, 2022. 
 
You asked the Plan to waive the copayment and coinsurance for the MRI and contrast injection. You say that 
you do not feel responsible since the procedure was ordered by your doctor. The Plan denied your request. The 
Plan says the correct copayment and coinsurance was applied. 
 
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 $175 
copayment for diagnostic radiology services at a free-standing radiology clinic. Your contract with the Plan also clearly says that you must pay a 20% coinsurance for medical supplies, 
including contrast agents. 
 
You have been asked to pay a $175 copayment for the MRI. You have also been asked to pay $7 for the 
contrast injection, which is 20% of the allowed amount ($35 allowed amount x 20% coinsurance = $7). The 
total for the procedure is $182. The MRI and contrast injection 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 and 
coinsurance for a magnetic resonance imaging (MRI) of the pelvis and a gadobutrol (contrast agent) injection 
provided on February 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 18, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the pre-authorization tool states that no prior 
authorization is required. The Plan denied your request. The Plan says the rendering provider is a non-
participating provider, and there is no referring provider involved in these services. The Plan also says that they 
did not authorization any services for the provider nor the facility. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on October 18, 2021, by 
an out-of-network (OON) provider.