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

 
We decided that the Plan does not have to pay for a telehealth visit provided on January 20, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the telehealth visit. You say that the service provided to the enrollee was 
medically necessary and you would like the claim processed for payment. The Plan denied your request. The 
Plan says the rendering provider is an OON 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 telehealth visit provided on January 20, 2022, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Genetic Testing provided on January 31, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Genetic Testing. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and we did not 
receive a PCP referral to review and approve. 
 
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 Genetic Testing provided on January 31, 2022 by 
an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on January 13, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the treatment received by the 
member was medically necessary and the physician provided a statement of medical necessity. The Plan denied 
your request. The Plan says the member was seen by a provider who is out-of-network for the member's plan. 
The Plan also says that this was denied due to no authorization for this date of service. 
 
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 subsequent nursing facility care provided on 
January 13, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve power mobility device (PMD) repairs (castors, tires and motor). 
 
You asked the Plan to pre-approve PMD repairs. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says that the services are not covered. 
 
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 confirmed in the additional information requested by us that the age of 
the scooter or when it was purchased is unknown. As there is no evidence of the age of the scooter, the 
reasonable and useful lifetime of the scooter cannot be determined. The file shows that the expense of repairs is 
less than the expense of replacing the scooter and the repairs requested are due to wear and tear. We find that 
the requested repairs are covered to put the equipment back in good condition and to make the scooter 
serviceable again. Therefore, we decided that the Plan has to pre-approve power mobility device (PMD) repairs 
(castors, tires and motor).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgery provided from 
December 13, 2021, to December 14, 2021. 
 
You asked the Plan to waive the copayment for the outpatient surgery. You say that you werent aware of any 
copayment. The Plan denied your request. The Plan says the copayment was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $175 
copayment for Medicare-covered services provided in an outpatient hospital.  
 
 
  You have been asked to pay $175 for the outpatient surgery. The outpatient surgery falls within the Outpatient 
surgery, including 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 outpatient surgery provided from December 
13, 2021, to December 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided from 
November 7, 2021, through November 13, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you reached your out-of-
pocket maximum so this should be covered. The Plan denied your request. The Plan says at the time the claim 
was received your out-of-pocket maximum had not been reached and the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $279 
copayment for Inpatient hospital care.   
 
 
You have been asked to pay $1067.92 which is less than the standard copayment for inpatient hospital stay 
because you met your maximum out -of -pocket. Inpatient hospital 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 inpatient hospital stay provided 
from November 7, 2021, through November 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you would like the claim to be paid or some type of 
support from the Plan. The Plan denied your request. The Plan says the rendering provider is an OON provider 
and there was no approved authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the 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 March 15, 2022, by an 
out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for psychotherapy provided on November 18, 
2021. 
 
You asked the Plan to waive the copayment for psychotherapy. You say that you have been going to this 
facility since November of last year. You say that you were never charged a copayment. The Plan denied your 
request. The Plan says you have been charged the correct copayment 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 each Medicare-covered in-network individual outpatient substance abuse session.  
 
 
 
 
 You have been asked to pay a $40 copayment for psychotherapy. Psychotherapy falls within the Outpatient 
substance abuse 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 
psychotherapy provided on November 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a wrist brace provided on January 18, 
2022. 
 
You asked the Plan to waive the coinsurance for a wrist brace. You say that you could not leave the office 
without the brace. You also say you needed the brace for your healing wrist. 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 20% 
coinsurance for durable medical equipment.  
 
 You have been asked to pay $19, which is 20% coinsurance of the allowed amount for a wrist brace ($95 
allowed amount x 20% coinsurance = $19). A wrist brace falls within the Durable Medical Equipment (DME) 
and Related Suppliesbenefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a wrist brace 
provided on January 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CPAP machine provided from June 3, 
2021, to November 3, 2021. 
 
You asked the Plan to waive the copayment for the CPAP machine. You say that you were not aware you 
would have to return the machine if not in use. The Plan denied your request. The Plan says the copayment was 
applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 10% 
coinsurance for covered DME items and related supplies.  
 
 
  You have been asked to pay $66.24 for the CPAP machine. 
 
Date of Service Allowed Amount Standard Coinsurance Member Liability 
June 3, 2021 $110.40 10% $11.04 
July 3, 2021 $110.40 10% $11.04 
August 3, 2021 $110.40 10% $11.04 
September 3, 2021 $110.40 10% $11.04 
October 3, 2021 $110.40 10% $11.04 
November 3, 2021 $110.40 10% $11.04 
Total:   $66.24 
 
 The CPAP machine falls 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 the CPAP machine provided from June 3, 2021, 
to November 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility services provided on December 20, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility services. You say that you would like the charges to fall 
under the facilities authorization and to allow payment per the Plan's benefits. The Plan denied your request. 
The Plan says the rendering provider is an OON 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 nursing facility services provided on 
December 20, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a thoracic, lumbar and sacral regions of the spine (TLSO), 
flexible brace that provides trunk support, upper thoracic region provided on January 24, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a TLSO, flexible brace that provides trunk support, upper thoracic region. You 
say that you needed the equipment as an emergency since you could not move much. You also say you could 
not take the medical order to the Plan, and that is why you had to buy it at the moment. The Plan denied your 
request. The Plan says this service was not authorized by network/primary care 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 a thoracic, lumbar and sacral regions of the spine 
(TLSO), flexible brace that provides trunk support, upper thoracic region provided on January 24, 2022, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services provided on November 16, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the imaging services. You say that you provided the service at the request of the 
referring provider which were medically necessary and would like the claim to be paid. The Plan denied your 
request. The Plan says the rendering and referring providers are both OON 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 imaging services provided on November 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 the office visit (99204) rendered by the out-of-network 
(OON) provider on January 5, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99204) rendered by the out-of-network (OON) provider on January 5, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a primary care office visit provided on 
January 21, 2022. 
 
You asked the Plan to waive the copayment for a primary care office visit. You say that you scheduled this 
appointment for your annual physical. You also say no medical condition were discussed. 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 $10 
copayment for a primary care office visit. The Plan contract also says that enrollees must pay a $0 copayment 
for an annual physical. The contract says if you receive services that address a medical condition during the 
same office visit, an additional cost share may apply. 
 
The medical record shows a medical condition was discussed, therefore, a cost sharing amount applies. You 
have been asked to pay a $10 copayment for a primary care office visit. A primary care office 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 primary care office visit provided on January 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care visit provided on March 18, 
2022. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that you are on a very tight 
budget and cannot afford extra bills. The Plan denied your request. The Plan says the copayment was applied 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 
copayment for each in-network office visit or telehealth visit to your POC, or other primary care provider, or a 
$40 copayment for each in-network office visit or telehealth visit to other providers for urgently needed 
services.  
 
 
  You have only been asked to pay the allowed amount of $27.23 for the urgent care visit rather than the standard 
$40 copayment. The urgent care visit falls within the Urgently Needed Services benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the urgent care visit provided on March 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a comprehensive eye exam provided on 
January 17, 2022. 
 
You asked the Plan to waive the deductible for the eye exam. You say that the Plan should have made a partial 
payment based on the contract. The Plan denied your request. The Plan says the correct amount was applied to 
your deductible. 
 
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 $150 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Vision Care benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $150 
deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not 
been met at the time the eye exam was received on January 17, 2022. Therefore, we decided that the Plan does 
not have to waive the deductible for a comprehensive eye exam provided on January 17, 2022.