Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient observation provided on April 21, 2022. 
 
You asked the Plan to pay for an inpatient observation. You say that this was medically necessary and should 
be covered. You depend on the staff to obtain proper authorizations. The Plan denied your request. The Plan 
says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an inpatient observation 
provided on April 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from June 8, 2022, to 
June 9, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that the pharmacy medication charge was 
denied. The Plan denied your request. The Plan says self-administered drugs are not covered when in critical 
care hospital. 
 
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 pay for the self-administered drugs 
provided from June 8, 2022, to June 9, 2022.  
 
  Benefits for the self-administered drugs 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: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the short-latency somatosensory evoked potential study (95938) 
provided on June 7, 2022. 
 
You asked the Plan to pay for short-latency somatosensory evoked potential study. You say that this service 
meets the medical necessity guidelines for coverage, and you would like this claim to be reconsidered for 
payment. The Plan denied your request. The Plan says that this service does not meet the requirements for 
coverage. 
 
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 records submitted do not include any evidence to support how the service at 
issue was initially billed or why it was denied. It is the burden of the Health Plan to substantiate their denial 
with evidence. In this case, the Plan's denial has not been substantiated so we must find in your favor. 
Therefore, we decided that the Plan has to pay for the short-latency somatosensory evoked potential study 
(95938) provided on June 7, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cardiac event monitor provided on August 18, 2022. 
 
You asked the Plan to pay for a cardiac event monitor. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a cardiac event monitor 
provided on August 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on July 08, 2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that you were billed for a consultation, 
but you dont know why. 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 physician/practitioner services, including doctors office visits (specialist). 
 
You have been asked to pay a $40 copayment for the office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits (specialist) benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the office visit provided on July 08, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on August 8, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on August 
8, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network nuclear stress test provided 
on August 31, 2022. 
 
You asked the Plan to waive the copayment for an in-network nuclear stress test. You say that you were told by 
the plan that there would not be a copayment for this service. 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 $180 
copayment for outpatient hospital services. 
 
You have been asked to pay a $180 copayment for an in-network nuclear stress test. This item/service falls 
within the outpatient hospital 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 in-network nuclear stress test provided on August 31, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for a COVID-19 test for the purpose of travel provided on August 3, 2022. 
 
You asked the Plan to pay for COVID-19 test for the purpose of travel. You say that you would like the Plan to 
pay for the COVID-19 test. The Plan denied your request. The Plan says that a COVID-19 test for travel is not 
a covered benefit. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for COVID-19 test for the purpose of travel by a contract provider. The file does not show 
that the Plan provided notice that COVID-19 test for the purpose of travel would not be covered. Under 
Medicare rules, this means COVID-19 test for the purpose of travel is considered approved by the Plan. 
Therefore, we decided that the Plan has to pay for a COVID-19 test for the purpose of travel provided on 
August 3, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 08, 2022. 
 
You asked the Plan to pay for lab services. You say that this was medically necessary and should be covered. 
The provider who sent the samples is in-network. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab services provided on 
July 08, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the x-rays provided on September 14, 2022. 
 
You asked the Plan to waive the copayment for the x-rays. You say that the copayment is too expensive. 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 $50 
copayment for routine radiology (x-rays). 
 
You have been asked to pay a $50 copayment for the x-rays. This item/service falls within the routine 
radiology (x-rays) 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 x-rays provided 
on September 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cystourethroscopy provided on August 1, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the cystourethroscopy. You say that the Plan portal indicates that no 
authorization is required for this procedure. The Plan denied your request. The Plan says unauthorized, out-of-
network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider at issue in this case is not a network provider with the Plan. 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 pay for the cystourethroscopy. Our reviewer says that the records do not indicate that the 
care provided was medically necessary. Our physician reviewer found there was no documentation indicating 
the procedure was needed on an urgent/emergent basis. It would have been medically reasonable to delay the 
services until when enrollee returned to their service area. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the cystourethroscopy have not been met.  
 
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 pay for the cystourethroscopy. Therefore, we decided that the Plan 
does not have to pay for a cystourethroscopy provided on August 1, 2022, by an out-of-network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on August 30, 2022. 
 
You asked the Plan to pay for the drug testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the drug testing 
provided on August 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network specialist office visit 
provided on August 29, 2022. 
 
You asked the Plan to waive the copayment for an in-network specialist office visit. You say that the provider 
was unable to remover your port, so you dont feel you should have to pay. 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 $15 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $15 copayment for an in-network specialist office visit. This item/service 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 an in-network specialist office visit provided on August 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient surgery provided on June 23, 2022. 
 
You asked the Plan to pay for outpatient surgery. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for outpatient surgery 
provided on June 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a therapeutic continuous glucose monitor (CGM) provided 
on September 21, 2022. 
 
You asked the Plan to pay for the CGM. You say that the services should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the date of service billed on this claim does not match the 
shipping date or the date or delivery. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record shows that the shipping date of this item was September 14, 2022, and the delivery date was 
September 17, 2022. Therefore, the date of service billed on this claim, September 21, 2022, does not meet 
Medicare rules. Therefore, we decided that the Plan does not have to pay for a therapeutic continuous glucose 
monitor (CGM) provided on September 21, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on June 02, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you are disputing the share cost. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $20 copayment for an ultrasound. This item/service 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 ultrasound provided on June 02, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgently needed services provided on 
October 5, 2022. 
 
You asked the Plan to waive the copayment for urgently needed services. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for urgently needed services.  
 
You have been asked to pay a $50 copayment for urgently needed services. This item/service 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 urgently 
needed services provided on October 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network allergy appointment 
provided on October 05, 2022. 
 
You asked the Plan to waive the copayment for an in-network allergy appointment. You say that the surgeon 
wanted you to see this allergist, not you. Therefore, you should not have to pay a copay. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $45 copayment for an in-network allergy appointment. This item/service 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 an in-network allergy appointment provided on October 05, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical removal of an implant body (D6100) provided 
on May 4, 2022. 
 
You asked the Plan to pay for the surgical removal of an implant body (D6100). You say that this was an 
emergency. You also say that the dentist did not complete the surgery and called the specialist to complete the 
rest of it. The Plan denied your request. The Plan says this was not authorized care. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
surgical removal of an implant body (D6100) provided on May 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility care provided on 
January 7, 2022, to February 25, 2022. 
 
You asked the Plan to waive the copayment for skilled nursing facility care. You say that you are disputing the 
share cost. 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 $184 per 
day for days 21-100 for skilled nursing facility care. This care lasted 5 days, resulting in a copayment amount 
of $920 ($184 per day for 5 days = $920).  
 
You have been asked to pay $184 per day for days 21-100 for skilled nursing facility care. This item/service 
falls within the skilled nursing facility 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 skilled nursing facility care provided on January 7, 2022, to February 25, 2022.