Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
December 29, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that your coverage 
includes ambulance services if you are 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 $200 
copayment per one-way ambulance trip.  
 
You have been asked to pay a $200 copayment for the ambulance transportation. Please note that cost share 
waivers apply to ER visit copayments when admitted.  The copayment for ambulance transportation still applies. The ambulance transportation falls within the 
Ambulance Services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance 
transportation provided on December 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Alcohol Detox admission to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve Alcohol Detox admission. You say that you would like to appeal the denial 
of the 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 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 
Alcohol Detox admission to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing December 22, 2021, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for drug testing. You say that you were not aware of the requirement of obtaining a 
prior authorization, specifically for this member's plan type at the time of rendering services. The Plan denied 
your request. The Plan says the rendering provider is a non-participating provider, and the referring provider 
involved in these services is a non-participating provider with the Plan. The Plan also says that they did not 
authorize any services for the rendering provider or the referring provider. 
 
 
 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 drug testing December 22, 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 wound care provided on December 1, 2021. 
 
You asked the Plan to waive the copayment for wound care. You say that you have been receiving services at 
this hospital since November and never had been charged a copay until now. 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 $200 
copayment for per visit for listed Medicare-covered services performed in outpatient hospital facility.  
 
You have been asked to pay $200 copayment for wound care. Wound care falls within the Outpatient hospital 
services benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for wound care provided on 
December 1, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the cost-sharing for Part B drugs provided on November 29, 2021. We 
decided that the Plan does not have to waive the cost-sharing for a specialist visit provided on November 29, 
2021, and a specialist visit and Part B drugs provided on January 6, 2022.  
 
You asked the Plan to waive the cost-sharing for a specialist visit with Part B drugs. You say that the Plan said 
the service was preapproved and you would only owe your copayment. The Plan says that the cost-sharing 
applied was correct. 
 
We decided that the Plan has to waive the cost-sharing for Part B drugs provided on November 29, 2021.  
 
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 Plan did not include pages of the Evidence of Coverage (EOC) 
corresponding to the correct benefit. Therefore, we decided that the Plan has to waive the cost-sharing for  
Part B drugs provided on November 29, 2021.  
 
We also decided that the Plan does not have to waive the cost-sharing for a specialist visit provided on 
November 29, 2021, and a specialist visit and Part B drugs provided on January 6, 2022. 
 
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 an in-network specialist visit. Your contract with the Plan also clearly says that you must pay a 
20% coinsurance for in-network Medicare Part B covered drugs. Therefore, we decided that the Plan does not 
have to waive the cost-sharing for a specialist visit provided on November 29, 2021, and a specialist visit and 
Part B drugs provided on January 6, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the consultation to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the consultation. You say that you do not have confidence in the other 
physicians at the in-network facility. The Plan denied your request. The Plan says the provider is out-of-
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 consultation in this appeal. We found no exception that would require the Plan to 
pre-approve the consultation. The records provided for review do not show that the office visit at issue is urgent 
or emergent. Therefore, we decided that the Plan does not have to pre-approve the consultation 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 pay for an office visit provided on December 23, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. 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 an office visit provided on December 23, 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 the inpatient hospital care treatment provided on February 1, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the inpatient hospital care treatment. You say that an authorization is not 
required for the service provided. The Plan denied your request. The Plan says the rendering provider is an 
OON provider and there was no referral from an in-network provider or an approved 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 inpatient hospital care treatment provided on 
February 1, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the durable medical equipment (DME) to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the DME. You say that you would like to see the OON provider and need it 
to be fixed because it is causing you pain. The Plan denied your request. The Plan says there is an in-network 
provider that is within the allowed distance that can provide the enrollee with the proper DME that is needed. 
 
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 
the durable medical equipment (DME) to be provided by an out-of-network (OON) provider.  
 Your complaint about your experience with an in-network provider is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on 
September 19, 2021. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you are not being charged 
the correct amount. 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 $230 
copayment for each one -way Medicare-covered ground ambulance trip.  
 
You have been asked to pay $230 copayment for ambulance transport. Ambulance transport falls within the 
Ambulance services benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance 
transport provided on September 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a specialist office visit. You say that you want the member to see this 
provider for his ability to help the member improve significantly in overall health with treatment plans. The 
Plan denied your request. The Plan says the services are available 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 
a specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on October 26, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory 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 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 laboratory services provided on October 26, 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 a CT provided on January 7, 2022. 
 
You asked the Plan to waive the copayment for a CT. You say that you were not aware of your change in your 
health benefits. You say that you have not had to pay a copayment for previous CT scans. The Plan denied your 
request. The Plan says you have been charged the correct copayment 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 $195 
copayment for all other diagnostic and nuclear medicine radiological services.  
 
 
 
 You have been asked to pay a $195 copayment for a CT. The CT falls within the Outpatient diagnostic tests 
and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a 
CT provided on January 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan 
provided on February 25, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that this test was for an existing health issue 
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 $180 
copayment for advanced imaging services in a PCP office, specialists office or free- standing radiological 
facility.  
 
 
 
 You have been asked to pay $180 copayment for a CT scan. CT scans fall within the Outpatient diagnostic 
tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for the computed tomography (CT) scan provided on February 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 8, 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 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 February 8, 2022 by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on October 20, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the rendering provider is a non-participating provider and, the referring 
provider involved in these services is a non-participating provider with the Plan. The Plan also says that they 
did not authorize any services for the rendering or referring provider. 
 
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 drug testing provided on October 20, 2021, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the specialist office visit. You say that the OON provider performed surgery 
the year prior, and you would like to continue to see the OON provider. The Plan denied your request. The Plan 
says they have approved a follow up visit with an in-network provider that provides the same quality of service, 
and a routine follow-up visit is not considered 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 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 
a specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insulin pump and supplies to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the insulin pump and supplies. You say that you would like to request an 
authorization to provide the enrollee with the supplies needed. The Plan denied your request. The Plan says the 
requesting provider is an OON provider and there are in-network providers that can provide the enrollee with 
the necessary supplies needed. 
 
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 
an insulin pump and supplies to be provided by an out-of-network (OON) provider.