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

 
We decided that the Plan does not have to pre-approve chiropractic care to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve OON chiropractic care. You say that you believe you are an in-network 
provider. The Plan denied your request. The Plan says you are not a network provider with the member's 
specific 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 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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
chiropractic care to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent ambulance transfer on November 1, 2021. 
 
You asked the Plan to pay for non-emergent ambulance transfer. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says despite multiple outreaches 
by the Health Plan, this provider has not submitted any clinical records to support the medical necessity of the 
service(s). 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
Based on this information, we decided that Medicare rules for coverage of non-emergent ambulance transfer 
have not been met. Therefore, we decided that the Plan does not have to pay for non-emergent ambulance 
transfer on November 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for basic life support, non-emergent ambulance 
service and ground mileage provided on May 9, 2022. 
 
You asked the Plan to waive the copayment for basic life support, non-emergent ambulance service and ground 
mileage. You say that this is the ambulance that came when 911 was called. 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 $245 
copayment for each one-way ground ambulance trip.  
 
You have been asked to pay a $245 copayment for basic life support, non-emergent ambulance service and 
ground mileage. This item/service falls within the one-way ground ambulance trip 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 basic life support, non-emergent ambulance service and ground 
mileage provided on May 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Durable medical equipment provided on 
April 05, 2022, to May 05, 2022. 
 
You asked the Plan to waive the coinsurance for Durable medical equipment. You say that you were told there 
would be no charge for this. 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 Durable medical equipment (DME). 
 
You have been asked to pay 20% coinsurance for Durable medical equipment. This item/service 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 Durable medical equipment provided on April 05, 2022, to May 05, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) hematologist/oncologist. 
 
You asked the Plan to pre-approve the OON visit. You say that you have been seeing this provider for your 
care and you wish to continue to see him. The Plan denied your request. The Plan says this provider is not in-
network and network providers are available.  You only see this provider for routine care (not active treatment) 
every six months, so your care can be managed by a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) hematologist/oncologist.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing care services provided on April 19, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the nursing care services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says while out-of-network benefits exist, they only apply to non-
routine dental care. A referral/authorization was not obtained prior to services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for nursing care services provided on April 19, 2022, 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical procedure provided on May 11, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for a surgical procedure. You say that you would like the claim reprocessed and 
paid. You say that the services rendered were medically necessary. The Plan denied your request. The Plan 
says an authorization was not obtained prior to performing the surgical procedure. 
 
  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 surgical procedure provided on May 11, 2022, 
by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance transportation provided on 
May 27, 2022. 
 
You asked the Plan to waive the copayment for an ambulance transportation. You say that the transport was 
ordered by the hospital. You say it was from one hospital to another. 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 $250 
copayment for a Medicare-covered one-way trip.  
 
You have been asked to pay a $250 copayment for an ambulance transportation. This item/service falls within 
the Ambulance 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 
ambulance transportation provided on May 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a magnetic resonance imaging (MRI) provided on June 21, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an MRI. You say that this should have been covered. The Plan denied your 
request. The Plan says there was no preauthorization by a primary care provider (this is different than a 
referral) for an OON provider or facility, and this was not an emergency. Therefore, the decision is upheld. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a magnetic resonance imaging (MRI) provided on 
June 21, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefit for the chronically ill 
(SSBCI) benefits. 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you were conditionally approved for this 
program. The Plan denied your request. The Plan says you do not meet criteria for the SSBCI program. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have one of 
the eligible conditions listed in the Evidence of Coverage. In addition, your primary care provider completed 
the form required for consideration for the SSBCI program and indicated that you do not require Intensive Care 
Management.  This is a required criterion for acceptance into the Plan's SSBCI program. Therefore, we decided 
that the Plan does not have to pre-approve special supplemental benefit for the chronically ill (SSBCI) benefits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the requested device is 
medically necessary. The Plan denied your request. The Plan says the requested device is not covered by 
Medicare or the Plan for the requested use. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pre-approve a pneumatic compression device (E0676).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a shoulder surgery provided on June 2, 
2022. 
 
You asked the Plan to waive the copayment for a shoulder surgery. You say that the provider needs to pay this 
copayment, you were having this surgery redone due to a medical mishap the first time. 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 $290 
copayment for outpatient surgery.  
 
You have been asked to pay a $290 copayment for a shoulder surgery. 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 copayment for a shoulder surgery 
provided on June 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for outpatient surgery on November 04, 2020. 
 
You asked the Plan to waive the deductible for outpatient surgery. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $400 deductible which applies to Outpatient surgery, including 
services provided at hospital facilities and ambulatory surgical centers.  
 
The item or service you asked the Plan to waive the deductible for falls within the Outpatient surgery, including 
services provided at hospital facilities and ambulatory surgical centers benefit category. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $400 deductible which applies to Outpatient 
surgery, including services provided at hospital facilities and ambulatory surgical centers. This cost sharing is a 
contractual obligation that had not been met at the time outpatient surgery was received on November 4, 2020. 
Therefore, we decided that the Plan does not have to waive the deductible for outpatient surgery on November 
04, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for duplex scans provided on January 20, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for duplex scans. You say that this should be covered. The Plan denied your request. 
The Plan says there was no preauthorization by a primary care provider (this is different than a referral) for an 
OON provider or facility, and this was not an emergency. Therefore, the decision is upheld. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal.  The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to 
pay for these items/services. Therefore, we decided that the Plan does not have to pay for duplex scans 
provided on January 20, 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 in-facility medicine review/ follow up provided on May 
20, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an in-facility medicine review/ follow up. You say that this should have already 
had authorization through the nursing facility. The Plan denied your request. The Plan says there was no 
preauthorization by a primary care provider (this is different than a referral) for an OON provider or facility, 
and this was not an emergency. Therefore, the decision is upheld. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an in-facility medicine review/ follow up provided 
on May 20, 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 wound care services provided on July 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the wound care services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says a referral/authorization was not obtained prior to services being 
rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for wound care services provided on July 14, 2022, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the laboratory services provided on April 
28, 2022. 
 
You asked the Plan to waive the deductible for the laboratory services. You say that you were not aware of the 
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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
deductible for outpatient diagnostic tests and therapeutic services and supplies (laboratory tests). 
 
You have been asked to pay a $100 deductible for the laboratory services. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and supplies (laboratory tests) 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 deductible for the laboratory services provided on April 28, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy visits provided from May 
16, 2022, to June 28, 2022. 
 
You asked the Plan to waive the copayments for physical therapy visits. You say that you received two bills 
totaling $200 that you feel you do not owe because you were told there would be no additional charges. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for physical therapy in an outpatient hospital facility.  
 
You have been asked to pay a copayment of $200 for physical therapy visits ($40 per visit x 5 visits = $200). 
This item/service falls within the Outpatient Rehabilitation 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 copayments for physical therapy visits provided from May 16, 2022, to June 28, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided on June 25, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that you did not know the service would be 
denied when you refused transport. The Plan denied your request. The Plan says this service is not covered 
when there is no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.   
The ambulance company did not provide transport services on June 25, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided on June 25, 2022.