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

 
We decided that the Plan does not have to pay for an office visit provided on March 23, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you were unaware that the provider was not 
contracted, and a prior authorization was needed. The Plan denied your request. The Plan says the rendering 
provider is an out-of-network 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 an office visit provided on March 23, 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 
January 6, 2022. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you were told by a sales 
representative that there was no ER cost share. You also say you should not have to pay copayment due to 
misrepresentation. 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 $120 
copayment for an emergency room visit.  The record shows the claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$120 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 January 6, 2022.  
 
Your complaint about misrepresentation from the sales representative 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 20, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that due to short time period, you were unable to get the 
authorization for this date of service. 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 they 
did not authorize any services for this provider or 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 July 20, 2021, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an intravenous (IV) iron infusion provided 
on November 22, 2021. 
 
You asked the Plan to reduce the copayment for an IV iron infusion. You say that this was for IV infusion of 
iron as you cannot tolerate iron in any other form. You also say that you cannot afford these costs. 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 $325 
copayment for in-network outpatient medical services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
the allowed amount of $218.56, which is less than the $325 copayment for an IV iron infusion. An IV iron 
infusion falls within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient 
Facilities and Ambulatory Surgical Centers benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment 
for an intravenous (IV) iron infusion provided on November 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a computed tomography (CT) scan of the 
abdomen and pelvis provided on November 29, 2021. 
 
You asked the Plan to reduce the copayment for a CT scan. You say that you feel like you are being 
overcharged because you had this test done at a hospital. You also say it would have been cheaper if you went 
to another place. 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, including CT scans at an outpatient hospital.  
 You have been asked to pay a $250 copayment for a CT scan. A CT scan 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 reduce the copayment 
for a computed tomography (CT) scan of the abdomen and pelvis provided on November 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cataract surgery provided on November 
23, 2021. 
 
You asked the Plan to waive the copayment for the cataract surgery. You say that you thought your copayment 
was only $250. The Plan denied your request. The Plan says the copayment 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 $300 
copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient 
facility.  
 
 You have been asked to pay $257.03, which is less than the standard $300 copayment for the cataract surgery. 
The cataract surgery 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 the cataract surgery provided on November 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 7, 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 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 authorize any services for this 
provider of this 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 January 7, 2021, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for gallbladder surgery provided on December 
21, 2021. 
 
You asked the Plan to waive the copayment for gallbladder surgery. You say that you met your maximum out-
of-pocket costs so, you should not have been billed a $250 copayment for your surgery. The Plan denied your 
request. The Plan says the copayment 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 a $250 
copayment for Medicare-covered outpatient surgery at an in-network, hospital outpatient facility.  
  You have been asked to pay $250 for gallbladder surgery. The gallbladder surgery falls within the Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit 
category. The records show that you had no longer met the maximum out-of-pocket amount due to claims 
being reprocessed. 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 gallbladder surgery provided on 
December 21, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services provided on December 16, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the radiology services. You say that you rely on the servicing facility to obtain 
referrals and would like the claim reprocessed for payment. The Plan denied your request. The Plan says the 
rendering and referring providers are both out-of-network provider and there was no 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 radiology services provided on December 16, 
2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Genetic testing provided on October 16, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Genetic testing. You say that this is medically necessary and used to help 
determine treatment options. The Plan denied your request. The Plan says prior authorization is required for 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 Genetic testing provided on October 16, 2021 by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Shoulder orthosis provided on December 20, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Shoulder orthosis. You say that you are separate from the hospital and not 
responsible to obtain authorization. The Plan denied your request. The Plan says the provider is out-of-network 
and it was determined these services were 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 Shoulder orthosis provided on December 20, 2021 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for cataract surgery provided on November 
30, 2021. 
 
You asked the Plan to reduce the copayment for cataract surgery. You say that the hospital is doing a scam and 
they keep calling you. You also say that you already paid the $100 and you have all the payment papers. 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 $370 
copayment for in-network outpatient surgery at an outpatient hospital.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$370 copayment for cataract surgery. Cataract surgery falls within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to reduce the copayment for cataract surgery provided on November 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT scan provided on December 3, 
2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you were told the CT scan would be 
covered at no cost. The Plan denied your request. The Plan says the copayment 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 $325 per 
day for other Medicare-covered diagnostic radiology services that are not ultrasounds.  
 
 You have been asked to pay $325 for the 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 CT Scan provided on December 3, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on January 7, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that the services rendered were medically 
necessary and a referral was obtained. The Plan denied your request. The Plan says the rendering and referring 
providers are both out-of-network providers and there was no 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 outpatient services provided on January 7, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transitional care management services and a domiciliary or 
rest home visit provided on September 10, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for transitional care management services and a domiciliary or rest home visit. You 
say that this provider was not responsible to obtain authorization, and the assisted living facility is responsible 
to obtain prior authorization for all of their patients. The Plan denied your request. The Plan says this provider 
is out-of-network with the Plan, and authorization was not obtained prior to the services being rendered. 
 
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 transitional care management services and a 
domiciliary or rest home visit provided on September 10, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 15, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the referring provider sends the specimen to 
your laboratory to process, and you would like the claim to be reprocessed for payment. The Plan denied your 
request. The Plan says the rendering and referring providers are both out-of-network providers and there was 
no 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 laboratory services provided on December 15, 
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 lab services provided on January 19, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for lab services. You say that these services were referred by the enrollee's 
physician. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because this provider is out-of-network with the Plan and the ordering physician was also out-of-network with 
the Plan. 
 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 lab services provided on January 19, 2022 by an 
out-of-network (OON) provider.