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

 
We decided that the Plan does not have to pay for an office visit and psychological test administration. 
provided on December 06, 2022. 
 
You asked the Plan to pay for an office visit and psychological test administration.. You say that no 
authorization is required. The Plan denied your request. The Plan says that 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit and 
psychological test administration. provided on December 06, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy treatments within a skilled nursing facility 
provided on July 11, 2022, to July 30, 2022. 
 
You asked the Plan to pay for physical therapy treatments within a skilled nursing facility. You say that there 
has not been a need for prior authorization for physical therapy. The Plan denied your request. The Plan says 
that 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for physical therapy 
treatments within a skilled nursing facility provided on July 11, 2022, to July 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on June 
17, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you disagree with the 
copayment. 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 $45 
copayment for physician/practitioner services/specialist. 
 
You have been asked to pay a $45 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist 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 office visit provided on June 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 29, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says that 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on August 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rest home visit provided on July 27, 2022. 
 
You asked the Plan to pay for a rest home visit. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says that 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a rest home visit 
provided on July 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging provided on August 17, 2022. 
 
You asked the Plan to pay for imaging. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says that 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for imaging provided on 
August 17, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a surgical eye procedure provided on 
December 19, 2022. 
 
You asked the Plan to reduce the copayment for a surgical eye procedure. You say that you were told that the 
copayment for this service was lower. 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 $325 
copayment for in-network surgical services performed at an outpatient hospital facility. 
 
You have been asked to pay a $325 copayment for a surgical eye procedure. This item/service falls within the 
in-network surgical services performed at an outpatient hospital facility benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to reduce the copayment for a surgical eye procedure provided on December 19, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient visit provided on December 23, 2022. 
 
You asked the Plan to pay for outpatient visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for outpatient visit provided 
on December 23, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the breathing treatment provided on 
November 1, 2022, November 3, 2022, and November 4, 2022. 
 
You asked the Plan to waive the copayment for the breathing treatments. You say that you were not aware of 
the cost sharing for these services. 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 $390 
copayment for Medicare-covered surgery or other services provided at an outpatient hospital, including but not 
limited to hospital or other facility charges and physician or surgical charges. 
 
 
 You have been asked to pay a $694.32 copayment for the breathing treatments because the allowed amount for 
these services is less than the $390 copayment. These items/services fall within the outpatient surgery and other 
medical services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the breathing treatment provided on November 1, 2022, 
November 3, 2022, and November 4, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the cataract removal surgery provided on 
July 28, 2022. 
 
You asked the Plan to waive the cost share for the cataract removal surgery. You say that you disagree with the 
cost share amount. 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. Your 
contract with the Plan says that there is a $800 deductible which applies to services at an ambulatory surgical 
center. The Plan contract also says there is a $275 copayment for in-network Medicare-covered surgery or 
other services provided to you at an ambulatory surgical center. 
 
You have been asked to pay $394.49 towards your deductible. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $800 deductible which applies to services at an ambulatory surgical 
center. This cost sharing is a contractual obligation that had not been met at the time the cataract removal 
surgery was received on July 28, 2022. You have also been asked to pay a $275 copayment for the cataract removal surgery. You have been asked to 
pay a total of $669.49 for the cataract removal surgery ($394.49 deductible + $275 copayment = $669.49). This 
item/service falls within the outpatient surgery 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 
cost share for the cataract removal surgery provided on July 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) provided on August 
26, 2022. 
 
You asked the Plan to pay for the magnetic resonance imaging (MRI). You say that you were informed that no 
authorization was needed for the services. The Plan denied your request. The Plan says that 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the magnetic resonance 
imaging (MRI) provided on August 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on September 07, 2022. 
 
You asked the Plan to pay for physical therapy. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says that 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for physical therapy 
provided on September 07, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on October 
27, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you disagree with the 
copayment. 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 $20 
copayment for physician/practitioner services/specialist. 
 
You have been asked to pay a $20 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist 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 office visit provided on October 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a sleep study provided on October 19, 
2022. 
 
You asked the Plan to waive the copayment for a sleep study. You say that you received an additional 
copayment for the first overnight sleep study 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 $95 
copayment for diagnostic procedures and tests other than electrocardiograms and colorectal screenings.  
 
You have been asked to pay a $95 copayment for a sleep study. The Plan confirmed this claim is being 
reprocessed with a $95 copayment. This item/service falls within the diagnostic procedures and tests other than 
electrocardiograms and colorectal screenings 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 sleep study provided on October 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for services to treat kidney disease provided 
on April 01, 2022. 
 
You asked the Plan to waive the coinsurance for services to treat kidney disease. You say that you disagree 
with the coinsurance. 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 20% 
coinsurance for services to treat kidney disease. 
 
You have been asked to pay 20% coinsurance for services to treat kidney disease. This item/service falls within 
the services to treat kidney disease 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 
services to treat kidney disease provided on April 01, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on October 21, 
2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you were told by your physician 
that you needed this ultrasound. 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 $160 
copayment for Medicare-covered radiological diagnostic services, including ultrasounds.  
 
You have been asked to pay $107.19, which is less than the standard $160 copayment for the ultrasound. This 
item/service falls within outpatient diagnostic tests and therapeutic 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 the ultrasound provided on October 21, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on November 17, 2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that you have seen this provider for 4 years 
and were informed that the services would be paid for. The Plan denied your request. The Plan says that 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the psychotherapy 
services provided on November 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on September 15, 2022, 
to October 26, 2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that you were not aware that a referral and 
authorization were required. The Plan denied your request. The Plan says that 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the psychotherapy 
services provided on September 15, 2022, to October 26, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an outpatient surgery provided on October 26, 2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that the provider did not 
surgically remove anything from your foot The Plan denied your request. The Plan says that the cost-share was 
applied correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided an Explanation of Benefits (EOB) or other 
documentation showing how the cost-sharing was applied. The Plan also has not provided medical records to 
address your dispute that the billed services did not take place. Therefore, we decided that the Plan has to waive 
the copayment for an outpatient surgery provided on October 26, 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 waive the deductible for an out-of-network specialist office visit 
provided on October 25, 2022. 
 
You asked the Plan to waive the deductible for a specialist office visit. You say that you have already paid your 
$35 copayment and do not have a deductible. 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. Your 
contract with the Plan says that there is a $500 deductible which applies to services obtained from a specialist.  
 
The item or service you asked the Plan to waive the deductible for falls within the out-of-network services 
obtained from a specialist benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $500 deductible which applies to services obtained from a specialist. This cost sharing is 
a contractual obligation that had not been met at the time a specialist office visit was received on October 25, 
2022. Therefore, we decided that the Plan does not have to waive the deductible for an out-of-network 
specialist office visit provided on October 25, 2022.