Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a wrist hand orthosis, without joints 
(L3906) provided on August 17, 2021. 
 
You asked the Plan to waive the coinsurance for a wrist hand orthosis, without joints. You say that you were 
unaware of the $77.50 that the explanation of benefits (EOB) stated that you owed. You also say that you do 
not agree that you should owe that. 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 20% 
coinsurance for durable medical equipment (DME) and related supplies.  
 
You have been asked to pay a $77.50 in coinsurance, which is 20% of the allowed amount for a wrist hand 
orthosis, without joints ($387.48 allowed amount x 20% coinsurance = $77.50). A wrist hand orthosis, without 
joints 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 coinsurance for a wrist hand orthosis, without joints (L3906) provided on August 
17, 2021.
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 
15, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that the doctor would not 
help unless you tried pain medications. 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 $35 
copayment for each in-person specialist visit.  
 
Although the treatment was not helpful, services were provided. Therefore, you have been asked to pay a $35 
copayment for the specialist office visit. The specialist office 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 a specialist office visit provided on June 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Diagnostic Tests provided on October 19, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Diagnostic Tests. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the care was not approved in compliance with the health 
plan's authorization procedures. 
 
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 Diagnostic Tests provided on October 19, 2021 by 
an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility (SNF) stay 
provided from May 7, 2021, to May 24, 2021. 
 
You asked the Plan to waive the copayment for the SNF stay. You say that you thought the service would be 
paid in full. The Plan denied your request. The Plan says the proper copayment was applied because the 
enrollee hit their annual maximum-out-of-pocket (MOOP) during the dates of service. 
 
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 each day for days 1 to 20. Prior to the date of service, the enrollee paid $330 towards the $500 
annual MOOP. Leaving the balance of $170 ($500 MOOP - $330 paid for the year). Therefore, only $170 was 
charged for the copayment out of the 18 days for the SNF stay. 
 You have been asked to pay a $170 copayment for the SNF stay. The SNF stay falls within Skilled Nursing 
Facility (SNF) 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 a skilled nursing 
facility (SNF) stay provided from May 7, 2021, to May 24, 2021.  
 
Your complaint about your experience with this provider is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a portable oxygen equipment provided on October 5, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the portable oxygen equipment. You say that to be released from the hospital you 
needed the equipment. The Plan denied your request. The Plan says the rendering provider or the enrollee did 
not reach out to the Plan to see if the service would be covered from an out-of-network provider. Also, the 
records submitted did not confirm the medical necessity of the equipment provided. 
 
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 portable oxygen equipment provided on October 
5, 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, medical examination and 
evaluation provided on November 2, 2021 
 You asked the Plan to pay for ophthalmological services, medical examination and evaluation. The Plan denied 
your request. The Plan says your Plan does not have out of network vision coverage. 
 
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit 
that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that the vision services were not provided by the 
Plans vision provider. Based on this information, we decided that the Plan's rules for coverage of the vision 
services have not been met. Therefore, we decided that the Plan does not have to pay for ophthalmological 
services, medical examination and evaluation provided on November 2, 2021
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for Physical Therapy on August 13, 2021 to 
November 8, 2021. 
 
You asked the Plan to waive the copayments for Physical Therapy. You say that you want to request waiver of 
cost share payments for physical therapy services. The Plan denied your request. The Plan says the copayment 
you are being charged 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 a $30 
copayment per visit for Physical Therapy. Nine unpaid for visits between August 13, 2021 to November 8, 
2021 result in a total cost share of $270. 
 
You have been asked to pay a $30 copayment per visit for Physical Therapy. Physical Therapy 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 on August 13, 2021 to November 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the specialist office visit. You say that you were referred to the out-of-
network provider by your primary care physician (PCP) and the in-network provider is father away. The Plan 
denied your request. The Plan says the PCP referred the enrollee to the out-of-network provider because they 
were told the neurologist said that but per the local neurologist office that was not accurate. The in-network 
provider is approximately the same distance from the enrollee's residence as the out-of-network provider is. 
Therefore, there is no justification the enrollee cannot see the in-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 
a specialist office visit to be provided 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 ophthalmic ultrasound and ophthalmic medical exam 
provided on September 28, 2021. 
 
You asked the Plan to pay for the ophthalmic ultrasound and ophthalmic medical exam. The Plan denied your 
request. The Plan says services must be provided by an in-network provider to be reviewed except for 
emergency services and certain mental health office visits. You have received eyecare at an out-of-network 
practice that is not covered by the Plan, since there are in-network providers for that care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services 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 an ophthalmic ultrasound and ophthalmic medical exam provided 
on September 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiidra. 
 
You asked the Plan to pre-approve Xiidra. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xiidra.  
 
Benefits for Xiidra may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on September 
20, 2021, and September 27, 2021. 
 
You asked the Plan to waive the copayment for the outpatient surgery. You say that the service provided could 
have been done in any room and the copayment should not be as high as it is. The Plan denied your request. 
The Plan says they overturned the cost share for September 20, 2021, in order to prevent the enrollee being 
charged for two cost shares for the same service. The Plan also says that the proper copayment was applied for 
September 27, 2021. 
  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 $295 
copayment for Medicare-covered surgery or other services provided to you 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 $295 copayment for the outpatient surgery. The outpatient surgery falls 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 outpatient surgery 
provided on September 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit and X-ray provided on 
November 23, 2021. 
 
You asked the Plan to waive the copayment for an office visit and X-ray. You say that you have never been 
charged for X-rays in the past, so the charges should be waived. The Plan denied your request. The Plan says 
the copayment amount charged 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 a $5 
copayment for primary care physician (PCP) visits/other health care professionals, and a $20 copayment for X-
rays. 
 You have been asked to pay a total of $20 for an office visit and X-ray. A $5 copayment for the office visit and 
a $15 copayment for the X-ray, which is less than the Plan's EOC documented $20 copayment for X-rays. 
Office visits fall within the Physician/Practitioner Services, Including Doctors Office Visits benefit category. 
X-rays fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an office visit and X-ray provided on November 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve surgery. You say that you disagree with the denial and would like to appeal. 
The Plan denied your request. The Plan says the request did not meet criteria and the service will only be 
coverered by non-contracted providers if the service is for an emergency and if it is medically necessary to go 
out of network. 
 
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 
surgery to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Physical Therapy on October 19, 2021 
 
You asked the Plan to waive the copayment for Physical Therapy. You say that you feel that they are not liable 
for this cost share because you thought the copay was $10. The Plan denied your request. The Plan says the 
copayment you are being charged 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 a $35 
copayment for Physical Therapy.  
 
You have been asked to pay a $35 copayment for Physical Therapy. Physical Therapy falls within the Physical 
Therapy 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 Physical Therapy on 
October 19, 2021
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram, routine ECG with at 
least 12 leads; with interpretation and report (93000) provided on November 24, 2021. 
 
You asked the Plan to waive the copayment for an electrocardiogram, routine ECG with at least 12 leads; with 
interpretation and report. You say that you were balance billed for your follow up with the cardiologist. The 
Plan denied your request. The Plan says you were charged the correct 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 $25 
copayment for Medicare-covered non-radiological diagnostic services.  
 
You have been asked to pay $13.01, which is less than the $25 copayment for an electrocardiogram, routine 
ECG with at least 12 leads; with interpretation and report. An electrocardiogram, routine ECG with at least 12 leads; with interpretation and report falls within the outpatient diagnostic tests and therapeutic services and 
supplies benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for an electrocardiogram, 
routine ECG with at least 12 leads; with interpretation and report (93000) provided on November 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on July 30, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory testing. You say that you performed the services because the 
referring physician ordered the testing. The Plan denied your request. The Plan says the rendering and referring 
providers are both out-of-network providers and there was no approved authorization. Also, the service 
rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory testing provided on July 30, 2021, 
by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the physical therapy visit provided on 
October 15, 2021. 
 
You asked the Plan to waive the copayment for the physical therapy visit. You say that the copayment is too 
much, and that you cannot afford it. The Plan denied your request. The Plan says the copayment amount 
charged 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 a $35 
copayment for Medicare-covered therapy visits.  
 
You have been asked to pay a $35 copayment for a physical therapy visit. Physical therapy visits fall 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 copayment for 
the physical therapy visit provided on October 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for removal of tunneled central venous catheter, without 
subcutaneous port or pump (36589), provided on October 5, 2021. 
 
You asked the Plan to pay for removal of tunneled central venous catheter, without subcutaneous port or pump 
(36589). The Plan denied your request. The Plan says there is no record of an approved referral being obtained 
from the members PCP to the Plan prior to the 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 did not pre-approve the 
services 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 removal of tunneled central venous catheter, without 
subcutaneous port or pump (36589), provided on October 5, 2021.