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

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided from June 10, 
2022, to June 15, 2022. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you were hospitalized due to 
covid and even after being released, you are still very ill and cannot pay these large amounts. The Plan denied 
your request. The Plan says this cost sharing was charged 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 $360 
copayment per day, for days 1 through 5 for inpatient hospital care. You had a five day inpatient stay, resulting 
in an $1800 copayment ($360 x 5 days = $1800). 
 
You have been asked to pay $1800 for an inpatient stay. This item/service falls within the inpatient hospital 
care benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for an inpatient stay provided from 
June 10, 2022, to June 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pain management visit for a transcutaneous electrical nerve 
stimulation (TENS) unit provided on March 4, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a TENS unit. You say that this should be covered. The Plan denied your request. 
The Plan says there was no preauthorization by a primary care provider (this is different than a referral) for an 
out-of-network (OON) provider or facility, and this was not an emergency. Therefore, the decision is upheld. 
 
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 pain management visit for a transcutaneous 
electrical nerve stimulation (TENS) unit provided on March 4, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on June 27, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that your blood 
pressure and blood sugar level were very high, and you were starting to pass out, so your family called 911. 
You also say that you did not want to go to the hospital and be exposed to different diseases. The Plan denied 
your request. The Plan says this service is not reimbursable. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 27, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on June 27, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care 
provided on March 01, 2022, to March 09, 2022. 
 
You asked the Plan to waive the copayment for the skilled nursing facility (SNF) care. You say that extending 
your stay 1 day was out of your control. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $188 
copayment for skilled nursing facility (SNF) care. 
 
You have been asked to pay a $188 copayment for the skilled nursing facility (SNF) care. This item/service 
falls within the skilled nursing facility (SNF) 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. Per the EOC, there is a $188 copayment per day for days 21-100 
for each skilled nursing facility benefit period. Your stay lasted 21 days, for a total of $188. Therefore, we decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care provided 
on March 01, 2022, to March 09, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on June 24, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
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 the laboratory services by a contract provider. The file does not show that the Plan 
provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the Plan. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on June 24, 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 pay for transfusion services provided on February 16, 2022 to 
February 17, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON transfusion services. You say that these services were medically 
necessary.  You also claim that you pre-certification is required for transfusions. The Plan denied your request. 
The Plan says pre-certification is required for all out-of-network care.  Unauthorized, out-of-network care is not 
covered. 
 
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 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 transfusion services provided on February 16, 2022 to February 
17, 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 office visit provided on January 26, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says as a member of our plan, the enrollee must use network providers. If the enrollee 
receives unauthorized care from an out-of-network provider, we may deny coverage and the enrollee will be 
responsible for the entire cost. 
 
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 office visit provided on January 26, 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 office visit provided on May 23, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollees network primary care provider (PCP) or plan must give the enrollee 
approval in advance before they can use providers not in the plan's network. This is called giving you a 
"referral." 
 
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 office visit provided on May 23, 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 cognitive assessment and care plan services provided on  
May 4, 2022. 
 
You asked the Plan to pay for cognitive assessment and care plan services. You say that the services were 
rendered to the member in an assisted living facility in good faith. The Plan denied your request. The Plan says 
the services were not urgent or emergent and the services could have been rendered by a Plan participating 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for cognitive assessment and care plan services provided on  
May 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient care provided on July 20, 
2022, to July 22, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you cannot afford the bills. The 
Plan denied your request. The Plan says this cost sharing was charged 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 $720 
copayment for inpatient hospital care. 
 
You have been asked to pay a $720 copayment for the inpatient care. This item/service falls within the 
inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Per the EOC, there is a $360 copayment per day for days 1-5 of inpatient care. Your stay 
lasted 2 days from July 20, 2022, to July 22, 2022, for a total of $720. Therefore, we decided that the Plan does 
not have to waive the copayment for the inpatient care provided on July 20, 2022, to July 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the ultrasound of the heart provided on 
June 22, 2022. 
 
You asked the Plan to reduce the copayment for the ultrasound of the heart. You say that your copayment 
should only be $30. The Plan denied your request. The Plan says this cost sharing was charged 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 $145 
copayment for radiological diagnostic services, not including x-rays. 
 
You have been asked to pay a $145 copayment for the ultrasound of the heart. This item/service falls within the 
radiological diagnostic services, not including x-rays 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 the ultrasound of the heart provided on June 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyewear purchased from an out-of-network provider on June 
8, 2022. 
 
You asked the Plan to pay for eyewear. You say that this should be covered under the same flex benefit that 
you had previously. The Plan denied your request. The Plan says the rules for coverage have not been met. 
 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 these services when they are obtained through the Plan's vision network. 
 
We looked at the file and the Plan's rules. The eyewear at issue was not obtained through the Plan's vision 
network. Based on this information, we decided that the Plan's rules for coverage of eyewear have not been 
met. Therefore, we decided that the Plan does not have to pay for eyewear purchased from an out-of-network 
provider on June 8, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the ultrasound provided on June 16, 2022. 
 
You asked the Plan to reduce the copayment for the ultrasound. You say that your copayment should only be 
$30. The Plan denied your request. The Plan says this cost sharing was charged 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 
$127.55 copayment for diagnostic radiology services at an outpatient facility (ultrasound). 
 
You have been asked to pay a $127.55 copayment for the ultrasound. This item/service falls within the 
diagnostic radiology services at an outpatient facility (ultrasound) 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. Per the EOC, there is a copayment of up to $175 
for diagnostic radiology services at an outpatient facility. Since the $127.55 allowed amount for the ultrasound 
is less than the copayment per the EOC, you are only responsible for the lesser amount. Therefore, we decided 
that the Plan does not have to reduce the copayment for the ultrasound provided on June 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp. 
 
You asked the Plan to pre-approve the ramp. You say that this is needed to leave home easily. The Plan denied 
your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a wheelchair ramp.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation (A0434) 
provided on January 10, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation services. You say that the 
services should be covered as you disagree with the charges. The Plan denied your request. The Plan says this 
cost sharing was charged 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $350 copayment for Ambulance services.  
 
 
  The enrollee has been asked to pay a $350 copayment for the ambulance transportation services. This 
item/service falls within the Ambulance services benefit category. This means that the enrollee has been asked 
to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the 
enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for ambulance transportation (A0434) provided on January 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ensure. 
 
You asked the Plan to pre-approve Ensure. You say that you are having trouble eating. You say that you do not 
have an appetite and are losing weight. You also say that you are hoping it will help you increase your energy 
so you can eat again. The Plan denied your request. The Plan says the requested item is not covered by 
Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve Ensure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient services on December 09, 2021. 
 
You asked the Plan to waive the copayment for outpatient services. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says this cost sharing was charged 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 $295 
copayment for all other Outpatient Services not provided in an Ambulatory Surgical Center. If you are having 
surgery in a hospital facility, you should check with your provider about whether you will be an inpatient or 
outpatient. Unless the provider writes an order to admit you as an inpatient to the hospital, you are an outpatient 
and pay the cost sharing amounts for outpatient surgery. Even if you stay in the hospital overnight, you might 
still be considered an outpatient. 
 
 
 You have been asked to pay a $295 copayment for outpatient services. This item/service 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 outpatient services on December 
09, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rest home visit provided on June 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the rest home visit. You say that the services should be paid due to the No 
Surprises Act. The Plan denied your request. The Plan says a referral/authorization was not obtained prior to 
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 a rest home visit provided on June 28, 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 a power operated scooter. 
 
You asked the Plan to pre-approve a power operated scooter. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage for this equipment 
have not been met. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power operated scooter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kerendia. 
 
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 Kerendia.  
 
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.