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

 
We decided that the Plan does not have to pay for podiatry services provided on September 13, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for podiatry services. You say that you would like to request reconsideration for 
payment. 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 podiatry services provided on September 13, 2021 
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 7, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained for 
this care. 
 
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 7, 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 flu vaccine provided on November 13, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the flu vaccine. You say that it is recommended for the enrollee to get the flu 
vaccine and it should be covered. 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 the flu vaccine provided on November 13, 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 10, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the referring provider ordered the testing, 
and it was medically necessary so 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 provided 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 10, 
2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited bilateral noninvasive physiologic studies of upper or 
lower extremity arteries provided on September 3, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for limited bilateral noninvasive physiologic studies of upper or lower extremity 
arteries. You say that you are appealing with supporting records. The Plan denied your request. The Plan says 
the services are not authorized because the provider is a non-network provider who does not work with the 
member's Plan, and the member was referred by a provider who also does not work with the member's plan. 
The Plan also says that the member's primary care physician did not refer for services. 
 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 limited bilateral noninvasive physiologic studies 
of upper or lower extremity arteries provided on September 3, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a nasal endoscopy provided on September 
17, 2021. 
 
You asked the Plan to waive the copayment for a nasal endoscopy. You say that you were told by the provider 
that this was a post op visit included as part of the surgery you had. You also say you were told the claim was 
billed incorrectly. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for in-network surgery services at a specialist's office.  
 
 The Plan confirmed with the provider that you are not being charged for the office visit and anything outside of 
the office visit is chargeable. The record shows this claim was approved, and you have a cost sharing amount. 
You have been asked to pay a $40 copayment for a nasal endoscopy. A nasal endoscopy falls within the 
Physician/Practitioner Services, Including Doctors Office Visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a nasal endoscopy provided on September 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation stay provided 
from August 25, 2021, to September 3, 2021. 
 
You asked the Plan to waive the copayment for the inpatient rehabilitation stay. You say that you had to pay 
$1,950 to the hospital and you shouldn't be billed an additional $1,950 by the rehabilitation hospital because it 
was for the same illness. 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 an in-
network $390 copayment per day, days 1 to 5 and an in-network $0 copayment per day, days 6 to 90 for 
inpatient hospital care, including inpatient rehabilitation. 
 You have been asked to pay a total of $1,950 ($390 x 5 days = $1,950). Inpatient rehabilitation stay 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 the inpatient 
rehabilitation stay provided from August 25, 2021, to September 3, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ER visit provided from November 29, 
2021, to November 30, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you were admitted into the hospital 
for testing within 24 hours and should not have to pay a copayment. 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 an in-
network $90 copayment for ER visits. 
 
 
 You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the Emergency care 
benefit category. The records show you were admitted to outpatient observation, which does not require the 
Plan to waive the ER copayment. 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 ER visit provided 
from November 29, 2021, to November 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 20, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that it was medically necessary to treat the enrollee. 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 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 pay for Assisted living facility services provided on January 1, 2021 
to August 6, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Assisted living facility services. 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 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 Assisted living facility services provided on 
January 1, 2021 to August 6, 2021 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 November 17, 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 with the Plan, 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 rending or referring providers. 
 
 
 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 November 17, 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 8, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the laboratory testing was ordered by the 
referring provider and the testing was medically necessary. 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 8, 
2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a nuclear stress test provided on January 
27, 2022. 
 
You asked the Plan to waive the copayment for the stress test. You say that your prior authorization letter did 
not mention any copayment for the test. 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 $180 
copayment for each advanced imaging service, including stress tests.  
 
You have been asked to pay a $180 copayment for the stress test. The stress test 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 nuclear stress test provided on January 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiidra drops. 
 
You asked the Plan to pre-approve the Xiidra. You say that Xiidra is medically necessary. The Plan denied 
your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
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 Xiidra drops.  
 
Benefits for the Xiidra may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 16, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that it was medically necessary to provide the 
service and would like reimbursement for the claim. 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 August 16, 
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 Chiropractic Care provided on July 15, 2020 to December 
22, 2020 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Chiropractic Care. You say that you would like to request reconsideration for 
payment. 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 Chiropractic Care provided on July 15, 2020 to 
December 22, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on January 28, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that authorization was not obtained prior 
to seeing this patient since it is the nursing facility's responsibility to get authorizations for their patients. 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 domiciliary or rest home visit provided on January 
28, 2022, by an out-of-network (OON) provider.