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

 
We decided that the Plan does not have to pay for Taxi transportation provided on February 25, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Taxi transportation. You say that you were unable to use other transportation. 
The Plan denied your request. The Plan says You must use the plan's approved vendor and set trips up 48 hours 
in advance for non-emergency transportation. 
 
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 Taxi transportation provided on February 25, 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 ophthalmological services provided on December 21, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for ophthalmological services. You say that a provider performing services in a 
nursing home facility is not responsible to obtain authorization, and their visit should fall under the 
authorization that the nursing home has for the stay of the patient. The Plan denied your request. The Plan says 
an authorization was not obtained prior to the services being rendered and the provider is not participating with 
the member's 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 ophthalmological services provided on December 
21, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
December 12, 2021, to December 17, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you had gastric bypass 
surgery in 2012 and the doctor was advised of this as well as your other medical history. You also say he 
prescribed you aspirin, which resulted in your internal organs bleeding. You also say you do not feel like you 
should be responsible for medical charges due to your doctor's mistake. The Plan denied your request. The Plan 
says you were 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 $298 
copayment per day, days 1 to 7, for in-network, inpatient hospital care.  
 You have been asked to pay a total of $1,490 for 5 days for inpatient hospital care ($298 copayment x 5 days = 
$1,490). Inpatient hospital care 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 inpatient hospital care provided from December 12, 2021, to 
December 17, 2021.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on October 11, 2021. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says prior 
authorization was not obtained by the provider or 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 did not pre-approve the 
service 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 physician's services provided on October 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for wound debridement procedures performed 
from September 7, 2021, to September 21, 2021. We also decided that the Plan does not have to waive the 
copayment for specialist services provided on September 28, 2021. 
 
You asked the Plan to waive the copayments for the wound debridement and specialist services. You say that 
you do not feel that these were surgical procedures. You say that you were unaware of the cost. 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 per visit for surgery or procedures at a hospital facility. 
 
Your contract with the Plan also clearly says that you must pay a $35 copayment per visit to a specialist. 
 
You have been asked to pay a $250 copayment for each of the 3 wound debridement procedures, for a total of 
$750. The wound debridement procedures fall within the Outpatient Surgery, Including Services Provided at 
Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. You have also been asked to 
pay a $35 copayment for the specialist services visit. The specialist services visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. The total for all visits is 
$785. 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 for wound debridement procedures performed 
from September 7, 2021, to September 21, 2021. We also decided that the Plan does not have to waive the 
copayment for specialist services provided on September 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on December 23, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that it is the facilities responsibility to obtain prior 
authorization and services were rendered in good faith. 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 a home health visit provided on December 23, 
2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Psychotherapy Services provided on August 19, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Psychotherapy 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 Psychotherapy Services provided on August 19, 
2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a commode chair and a folding, wheeled 
walker provided on April 28, 2021. 
 
You asked the Plan to waive the copayment for a commode chair and a folding, wheeled walker. You say that 
you feel these items were unnecessary and you did not use them. The Plan denied your request. The Plan says 
you were 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 20% 
coinsurance for each Medicare-covered durable medical equipment item.  
 
You have been asked to pay $22.75 in coinsurance, which is 20% of the allowed amount for a commode chair 
and a folding, wheeled walker ($113.81 allowed amount x 20% coinsurance = $22.75). Commode chairs and  folding, wheeled walkers fall within the durable medical equipment (DME) and related 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 commode chair and a folding, wheeled 
walker provided on April 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telehealth visit provided on December 
15, 2021. 
 
You asked the Plan to waive the copayment for a telehealth visit. You say that you were expecting an in-person 
office visit. 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 $45 
copayment for specialist telehealth visits.  
 
You have been asked to pay $45 copayment for a specialist telehealth visit. A specialist telehealth visit falls 
within the Physician/Practitioner services, including doctor's 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 December 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy visits provided from September 7, 2021, 
to November 6, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physical therapy visits. You say that you could not find an in-network 
provider and you would like the Plan to pay for the visits. The Plan denied your request. The Plan says they 
confirmed with the out-of-network provider, and they do not take any insurance and all patients are told they do 
not accept insurance. There are 5 in-network providers near the enrollee's residence that provide the same 
quality of service as the out-of-network provider. Also, there was no approved authorization and the services 
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 physical therapy visits provided from 
September 7, 2021, to November 6, 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 a home health visit provided on November 15, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that it is the facilities responsibility to obtain prior 
authorization and services were rendered in good faith. 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 a home health visit provided on November 15, 
2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises and activities, and manual therapy 
techniques provided on January 5, 2022, to January 6, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for therapeutic exercises and activities, and manual therapy techniques. You say that 
you would like reconsideration stating the provider referral is submitted. The Plan denied your request. The 
Plan says this provider is not a network provider with the Plan, and the referring provider is non-part. The Plan 
also says 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 therapeutic exercises and activities, and manual 
therapy techniques provided on January 5, 2022, to January 6, 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 an office visit provided on July 13, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that this was an office visit, and you were not aware that 
authorization/referral was not obtained. The Plan denied your request. The Plan says this provider is not a 
network provider with the Plan and the services were not referred by a network provider or rendered in an in-
network facility. The Plan also says that they have also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on July 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 (80048, 85610, and 36415) provided 
on February 1, 2021. 
 
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 the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say all services billed by the SNF (including those 
furnished under arrangements with an outside supplier) for a resident of a SNF in a covered Part A stay are 
included in the SNF's Part A bill. 
 
We looked at the file and Medicare rules. The file shows the billed services for February 1, 2021, are not listed 
as excluded from consolidated billing. The enrollee was inpatient at a participating SNF from January 29, 2021, 
through February 14, 2021. The billed services should be included in the SNFs bill. Therefore, we decided that 
the Plan does not have to pay for the laboratory services (80048, 85610, and 36415) provided on February 1, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on December 21, 2021. 
 
You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says an eye refraction 
is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye 
exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. 
 
We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of 
any eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to 
pay for an eye refraction provided on December 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 30, 2021. 
 
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 the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on July 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit for physician's services to be provided the 
requested out-of-network provider. 
 
You asked the Plan to pre-approve an office visit for physician's services to be provided by the requested out-
of-network provider. The Plan denied your request. The Plan says there are in-network providers available that 
can provide the 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office 
visit for physician's services to be provided by the requested out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on 
December 8, 2021. 
 
You asked the Plan to waive the copayment for a specialist telehealth visit. 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 $50 
copayment for an in-network specialist office visit at an independent office.  
 
The medical record shows you had a routine specialist follow up visit on December 8, 2021. You have been 
asked to pay a $50 copayment for a specialist telehealth visit. A specialist 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 a specialist telehealth visit provided on December 8, 2021.