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

 
We decided that the Plan does not have to pay for non-transport ambulance services provided on May 15, 2022. 
 
You asked the Plan to pay for the non-transport ambulance services. You say that your finger was cut very 
badly and bleeding, so you needed medical attention.  You said that you cannot drive due to epilepsy, which is 
why you called for an ambulance. You said that you cannot afford this bill. The Plan denied your request. The 
Plan says non-transport ambulance services are not covered. 
 
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 May 15, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for non-transport ambulance services provided on 
May 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on April 22, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that most of your employees are sick 
and it was not possible for you to get the authorization before the services were rendered. The Plan denied your 
request. The Plan says services from non-participating providers are not covered unless preauthorized. 
 
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 April 
22, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92004) provided on March 11, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the eye exam. You say that unless the facility is not a network provider, this bill 
should be paid. The Plan denied your request. The Plan says you did not obtain plan approval prior to receiving 
this service from the non-contracted provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when you use a doctor in the Plan's vision network. 
 
We looked at the file and the Plan's rules. This service was rendered by an OON provider, and not an in-
network vision provider as required by the Plan. Based on this information, we decided that the Plan's rules for 
coverage of the eye exam have not been met. Therefore, we decided that the Plan does not have to pay for the 
eye exam (92004) provided on March 11, 2022, 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 wrist, hand, and finger orthosis provided on March 7, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a wrist, hand, and finger orthosis. You say that the health plan is responsible for 
all durable medical equipment. The Plan denied your request. The Plan says the rendering provider and the 
referring provider are non-participating providers with the Plan. The Plan also says that they did not authorize 
any services for these 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 wrist, hand, and finger orthosis provided on 
March 7, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided from March 23, 
2022, to March 24, 2022. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you have been overcharged for 
this copayment. The Plan denied your request. The Plan says the copayment that was applied was 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 $200 
copayment for inpatient hospital care.  
 
You have been asked to pay a $200 copayment for an inpatient stay. An inpatient 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 an inpatient stay provided 
from March 23, 2022, to March 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on April 14, 2022. 
 
You asked the Plan to pay for the medical services. You say that these services should be covered. The Plan 
denied your request. The Plan says the provider has opted-out of Medicare, so this service cannot be paid. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for medical 
services provided on April 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on May 26, 2021. 
 
You asked the Plan to pay for the medical services. You say that the patient's hospice election ended prior to 
the date of service. The Plan denied your request. The Plan says Original Medicare is responsible for this claim. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
 The enrollee ended Medicare Hospice benefits on May 22, 2021. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for medical services provided 
on May 26, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for mental health services provided from 
December 28, 2021, to May 11, 2022. 
 
You asked the Plan to waive the deductible for the mental health services. You say that previous claims were 
paid in full. 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 $750 deductible which applies to certain items and services.  
 
The mental health services fall within the Outpatient Mental Health Care benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is $750 deductible which applies to 
certain items and services. This cost sharing is a contractual obligation that had not been met at the time the 
mental health services were received from December 28, 2021, to May 11, 2022. The file also shows that the 
Plan ceased cost share waivers for COVID-19 prior to these dates of service. Therefore, we decided that the 
Plan does not have to waive the deductible for mental health services provided from December 28, 2021, to 
May 11, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for out-of-network rehabilitation visits 
provided from January 12, 2022, to April 1, 2022. 
 
You asked the Plan to waive the copayment for out-of-network rehabilitation visits. You say that a $35 
copayment per visit is too high of an amount. The Plan denied your request. The Plan says the copayments that 
were applied were 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 pulmonary rehabilitation services. You had 30 visits, giving the total copayment amount of 
$1050 ($35 x 30 visits = $1050). 
 
You have been asked to pay a $1050 copayment for out-of-network rehabilitation visits. Out-of-network 
rehabilitation visits falls within the Pulmonary 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 out-of-network rehabilitation 
visits provided from January 12, 2022, to April 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on June 17, 2021. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary and 
provided in good faith. The Plan denied your request. The Plan says the patient was enrolled in hospice on the 
date of service, so the Plan is not responsible for this bill. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided on June 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids (E1399). 
 
You asked the Plan to pre-approve hearing aids. You say that you disagree with the denial and are requesting 
reconsideration for your hearing aids. The Plan denied your request. The Plan says your benefit only covers 
TruHearing hearing aids. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan contract says 
you must see a TruHearing provider to use this benefit.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids have not been met. Specifically, you must use a TruHearing provider to use your 
hearing aid benefit. Therefore, we decided that the Plan does not have to pre-approve hearing aids (E1399).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a lab service provided on May 21, 2022. 
 
You asked the Plan to waive the coinsurance for a lab service. You say that you didn't have a choice as to who 
you saw for this service. You were at an in-network facility. The Plan denied your request. The Plan says the 
coinsurance applied was 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 50% 
coinsurance for out-of-network lab services. The allowed amount of this service is $36.50, resulting in a 
coinsurance amount of $18.25 ($36.50 x 50% = $18.25). 
 
You have been asked to pay a $18.25 coinsurance for a lab service. A lab service falls within the Out-Of-
Network Outpatient Hospital Services Lab 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 
coinsurance for a lab service provided on May 21, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound on April 13, 2022. 
 
You asked the Plan to waive the copayment for ultrasound. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing 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 $175 
copayment for Medicare-covered radiological diagnostic services, not including X-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic). Covered service 
include but are not limited to other outpatient diagnostic tests -Radiological diagnostic services, not including 
x-rays. The provider billed in the amount of $1,198 and the allowed amount is $100.90. This is less than the 
copayment amount. Therefore, results in the total cost sharing amount of $100.90. 
 
 
 You have been asked to pay a $100.90 copayment, which is less than the copayment for ultrasound. Ultrasound 
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 ultrasound on April 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on December 22, 
2021. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you should not have a 
copayment for this visit, as you were in a skilled nursing facility at the time. The Plan denied your request. The 
Plan says the copayment that was applied was 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 $50 
copayment for physician/practitioner services, including doctor's office visits.  
 
You have been asked to pay a $50 copayment for a specialist visit. A specialist 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 visit provided on December 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Stelara injection on June 02, 2022. 
 
You asked the Plan to waive the coinsurance for Stelara injection. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says the cost sharing 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 20% 
coinsurance of the cost for Medicare Part B prescription drugs. These drugs are covered under Part B of 
Original Medicare. Members of our plan receive coverage for these drugs through our plan. Covered drugs 
include drugs that usually arent self-administered by the patient and are injected or infused while you are 
getting physician, hospital outpatient, or ambulatory surgical center services. The provider billed in the amount 
of $35,318.97 and the allowed amount is $6,250.60. The Plan paid $5,049. $6,250.60 - $5,049 = $1,201.6. 
Therefore, results in the total cost sharing amount of $1,201.60. 
 
 
 You have been asked to pay a 20% coinsurance for Stelara injection. Stelara injections fall within the Medicare 
Part B prescription drugs 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 Stelara 
injection on June 02, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on April 27, 2022. 
 
You asked the Plan to pay for the medical services. You say that this service was billed correctly. The Plan 
denied your request. The Plan says you billed with an incorrect POS code on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill with the appropriate Place of 
Service (POS) code.  POS code 22 indicates that the service was performed at an on-campus outpatient hospital 
facility.  POS code 21 indicates that the service was performed in an inpatient hospital setting. Records show 
that you billed POS 22 on this claim.  However, the billing records confirm that this patient was an inpatient in 
the hospital at the time of service.  As a result, you billed with an incorrect POS code. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided on April 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Sprint trial. 
 
You asked the Plan to pre-approve a Sprint trial. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Sprint trial. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has chronic low back pain. The enrollee has had medication trials, Physical therapy 
as well as Heat applications. The enrollee's imaging shows multi-level disc protrusions as well as facet 
arthropathy. This is considered experimental/ investigational for low back pain. Therefore, the enrollee does 
not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Sprint trial have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Sprint trial.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for office visit on May 09, 2022. 
 
You asked the Plan to waive the deductible for office visit. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
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 $1000 deductible which applies to Physician/Practitioner services, 
including doctor's office visits.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
Physician/Practitioner services, including doctor's office visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $1000 deductible which applies to Physician/Practitioner 
services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at 
the time office visit was received on May 9, 2022. Therefore, we decided that the Plan does not have to waive 
the deductible for office visit on May 09, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the requested hospital bed is 
medically necessary. The Plan denied your request. The Plan says total electric beds have extra features that are 
not needed at home. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for office visit on October 20, 2021. 
 
You asked the Plan to waive the deductible for office visit. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
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 $1,500 deductible which applies to Physician/Practitioner services, 
including doctor's office visits.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
Physician/Practitioner services, including doctor's office visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $1,500 deductible which applies to Physician/Practitioner 
services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at 
the time office visit was received on October 20, 2021. Therefore, we decided that the Plan does not have to 
waive the deductible for office visit on October 20, 2021.