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

 
We decided that the Plan does not have to pay for the office visit provided on October 6, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the diagnosis does not meet medical necessity 
incorrectly. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the office visit was urgent or emergent. Therefore, we decided that the Plan does 
not have to pay for the office visit provided on October 6, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments and coinsurance for diagnostic eye exams and 
a bevacizumab injection provided from March 15, 2022, to April 15, 2022. 
 
You asked the Plan to waive the copayments and coinsurance for the eye exams and injection. You say that the 
injection caused a floater in your eye. You say that you should not have to pay for these services. The Plan 
denied your request. The Plan says the correct copayments and coinsurance were 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 $35 
copayment for eye exams to diagnose and treat diseases and conditions of the eyes. 
 
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for Part B drugs. You have been asked to pay a $35 copayment for each of the 3 eye exams, for a total of $105 ($35 copayment 
x 3 visits = $105). The eye exams fall within the Vision Care benefit category. You have also been asked to pay 
$13.57 for the injection, which is 20% of the allowed amount ($67.86 allowed amount x 20% coinsurance = 
$13.57). The injection falls within the Medicare Part B Prescription Drugs benefit category. The total for all 
services is $118.57. 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 and coinsurance for diagnostic eye 
exams and a bevacizumab injection provided from March 15, 2022, to April 15, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services rendered by the out-of-network 
(OON) provider on March 23, 2022 and March 29, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. 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 the physical therapy services rendered by the out-of-network (OON) provider on 
March 23, 2022 and March 29, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services you received from a 
Licensed Clinical Professional Counselor from October 13, 2021, to December 16, 2021. 
 
You asked the Plan to pay for the outpatient mental health services. You say that you began seeing this 
provider before you turned 65.  You said that these are ongoing services, and you need to understand why these 
services are not being covered. The Plan denied your request. The Plan says you saw a provider type that is 
ineligible for Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that the only provider types eligible to provide 
Medicare-covered mental health services are as follows: Physicians, Clinical Psychologists, Clinical Social 
Workers, Clinical Nurse Specialists, Nurse Practitioners, Physician Assistants, Certified Nurse-Midwives, 
Independently Practicing Psychologists, and Certified Registered Nurse Anesthetists.  Licensed Professional 
Counselors are not eligible provider types to provide outpatient mental health services for Medicare patients.  
You received the services in dispute from a Licensed Professional Counselor, not a valid provider type. 
Therefore, we decided that the Plan does not have to pay for outpatient mental health services you received 
from a Licensed Clinical Professional Counselor from October 13, 2021, to December 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
thorax provided on May 19, 2022. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you have had these scans done in the 
past and had no copayments. 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 $300 
copayment for diagnostic radiology services, including CT scans.  
 
You have been asked to pay $136.67, which is less than the $300 copayment for the CT scan. The 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 waive the copayment for a computed tomography (CT) scan of the thorax provided on May 
19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telehealth visit provided on April 27, 
2022. 
 
You asked the Plan to waive the copayment for the telehealth visit. You say that you never spoke to anyone 
from this providers office on that date, or ever. 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 $20 
copayment for telehealth services.  
 
You have been asked to pay a $20 copayment for telehealth services. A telehealth 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 the telehealth visit provided on April 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an out-of-network specialist provided on 
October 1, 2021. 
 
You asked the Plan to waive the copayment for an out-of-network specialist. You say that you did not know 
that the provider you saw was out-of-network at the time of the visit. The Plan denied your request. The Plan 
says the copayment applied was 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 $55 
copayment for out-of-network Medicare-covered specialist visit.  
 
You have been asked to pay a $55 copayment for an out-of-network specialist. An out-of-network specialist 
falls within the Out-Of-Network Medicare-Covered Specialist Visit 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 out-of-network specialist provided on October 1, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a transthoracic echocardiogram (TTE) 
with doppler provided on April 12, 2022. 
 
You asked the Plan to waive the coinsurance for the TTE with doppler. You say that you thought this was just 
an EKG. The Plan denied your request. The Plan says the correct 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 20% 
coinsurance for diagnostic procedures and tests.  
 
 
 
 
 
 
 
 You have been asked to pay $89.42, which is 20% of the allowed amount for the TTE with doppler ($447.08 
allowed amount x 20% coinsurance = $89.42). The TTE with doppler is an ultrasound procedure and 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 coinsurance for a transthoracic echocardiogram (TTE) with doppler provided on 
April 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a C-PAP machine provided on April 13, 
2022. 
 
You asked the Plan to waive the coinsurance for a C-PAP machine. You say that you should not have a 
coinsurance for this. The Plan denied your request. The Plan says the coinsurance applied was 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 20% 
coinsurance for durable medical equipment (DME). The allowed amount of this item is $42.80 resulting in a 
coinsurance amount of $8.56 ($42.80 x 20% = $8.56). 
 
 
 
 
 
 You have been asked to pay a $8.56 coinsurance for a C-PAP machine. A C-PAP machine falls within the 
Durable Medical Equipment (DME) 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 a 
C-PAP machine provided on April 13, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve skilled nursing facility (SNF) services. You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says the criteria for 
admission to SNF have not been met. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve skilled nursing facility (SNF) services. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the patient does 
not require care in a skilled nursing facility (SNF). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of skilled nursing facility (SNF) services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 6, 2022. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the services 
were provided by a provider who chose not to receive Medicare funds. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
physician's services provided on January 6, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $90 copayment for an emergency room visit on March 8, 
2022. 
 
You asked the Plan to waive the $90 copayment for an emergency room visit. You say that you are not 
responsible for the copayment because the emergency room visit should not have been necessary. The Plan 
denied your request. The Plan says the copayment 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 a $90 
copayment for an emergency room visit.  
 
You have been asked to pay a $90 copayment for an emergency room visit. An emergency room 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 $90 copayment for an 
emergency room visit on March 8, 2022.  
 Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 25, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. The Plan denied your request. The Plan 
says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on April 7, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you cannot afford the cost of the claim. The Plan denied 
your request. The Plan says at the time of the office visit there was no pre-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 office visit at issue in this appeal. The Plan did not pre-approve the 
office visit at issue. We found no exception that would require the Plan to pay for the office visit. Therefore, we 
decided that the Plan does not have to pay for office visit provided on April 7, 2022, 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 urgent care visit provided on December 
21, 2021. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you feel you should not have 
to pay this copayment. The Plan denied your request. The Plan says the copayment applied was 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 $45 
copayment for urgently needed services.  
 
You have been asked to pay a $45 copayment for an urgent care visit. An urgent care visit falls within the 
Urgently Needed 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 an urgent 
care visit provided on December 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on May 4, 
2022. 
 
You asked the Plan to waive the copayment for lab services. You say that this should be waived since its more 
then what the plan is paying. 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 $15 
copayment for Medicare covered laboratory tests.  
 
You have been asked to pay $15 copayment for lab services. 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 laboratory services provided on May 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses purchased on March 11, 2022. 
 You asked the Plan to pay for the eyeglasses. You say that you get a $100.00 credit towards the hardware on 
your glasses every two years. The Plan denied your request. The Plan says eyeglasses (lenses and frames) are 
not covered under the plan benefit package that you are enrolled in. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for the eyeglasses purchased on March 11, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on September 28, 2020. 
 
You asked the Plan to pay for the medical services. You say that this bill was timely filed. The Plan denied 
your request. The Plan says Original Medicare is responsible for this claim due to the patient's hospice election. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on September 26, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for medical services 
provided on September 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92014) and determination of refractive state 
(92015) provided on January 20, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the eye exam and determination of refractive state. You say that your eyes, feet, 
and hands need to be checked every year because you are a diabetic. You also say that you have seen this 
provider for many years. The Plan denied your request. The Plan says these services were rendered by an OON 
provider. The Plan also says you did not contact the Plan to inquire whether this treating provider was in-
network or OON. 
 
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 received from a provider in the Plan's approved vision 
care network. 
 
 
 
 
 We looked at the file and the Plan's rules. The record shows that you received these services from an OON 
provider. Based on this information, we decided that the Plan's rules for coverage of the eye exam and 
determination of refractive state have not been met. Therefore, we decided that the Plan does not have to pay 
for the eye exam (92014) and determination of refractive state (92015) provided on January 20, 2022 by an out-
of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on September 27, 2020. 
 
You asked the Plan to pay for the medical services. You say that this claim should be considered timely filed. 
The Plan denied your request. The Plan says Original Medicare, not the Plan, is responsible for this claim. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 The enrollee ended Medicare Hospice benefits on September 26, 2020. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for medical services 
provided on September 27, 2020.