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

 
We decided that the Plan does not have to waive the copayment for the mental health visit provided from 
December 21, 2021, to December 27, 2021. 
 
You asked the Plan to waive the copayment for the mental health visit. You say that these services should be 
covered. The Plan denied your request. The Plan says the copayment 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 $370 
in-network copayment per day, days 1 to 5, $0 copayment per day, days 6 to 90. 
 
 
 You have been asked to pay a total of $1,480 ($370 x 4 days = $1,480). Inpatient mental health visit falls 
within the Inpatient mental health 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 the mental health visit provided from December 21, 2021, to December 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for hand finger orthosis (L3913) provided on 
January 6, 2022. 
 
You asked the Plan to waive the coinsurance for the hand finger orthosis. You say that the coinsurance should 
be covered as you disagree with the charges. The Plan denied your request. The Plan says the coinsurance 
applied correctly based on the services provided. 
 
 
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 20% coinsurance for the hand finger orthosis (total allowed is $533.02 x 20% = 
$106.60). Hand finger orthosis 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 hand finger orthosis (L3913) provided on 
January 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) rendered by the out-of-network 
(OON) provider on October 8, 2021. 
 
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 (99203) rendered by the out-of-network (OON) provider on October 8, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (83036) rendered by the out-of-
network (OON) provider on August 26, 2021. 
 
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 laboratory service (83036) rendered by the out-of-network (OON) provider on 
August 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (82542, 84228, G0480) rendered by 
the out-of-network (OON) provider on December 16, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. 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 the laboratory services (82542, 84228, G0480) rendered by the out-of-network 
(OON) provider on December 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on December 8, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a specialist office visit. You say that you have always called the Plan's customer 
service phone number, and in this case, you requested a number for an ear, nose, and throat doctor (ENT). You 
also say you would not have gone to an out-of-network because you have always called this Plan for referrals 
and telephone numbers, so you thought you were always getting correct information. The Plan denied your 
request. The Plan says they reviewed the call history and they do not have a record of the call where the 
customer service department provider you with this provider's name as an in-network provider, and there is no 
evidence of medical necessity. 
 
 
 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 specialist office visit provided on December 8, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to change the specialist office visits on dates April 23, 2021, May 14, 
2021, and August 13, 2021, to an in-network benefit level that was provided by an out-of-network (OON) 
provider. 
 You asked the Plan to change the specialist office visits. You say that you believed that the provider was an in-
network provider and would like the bills changed to in-network instead of out-of-network. The Plan denied 
your request. The Plan says for the date of service of April 23, 2021, the claim was processed as 
urgent/emergent care and there was no cost share charged to the enrollee. For the dates of service of May 14, 
2021, and August 13, 2021, the proper cost share for an out-of-network provider was charged for the service 
that was rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that enrollees may choose to receive care from out-of-network providers using the Plans Preferred 
Provider Organization (PPO) benefits. 
 
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. We found no exception that would 
require the Plan to change these items/services to an in-network benefit level. Therefore, we decided that the 
Plan does not have to change the specialist office visits on dates April 23, 2021, May 14, 2021, and August 13, 
2021, to an in-network benefit level that was provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (81001) rendered by the out-of-
network (OON) provider on November 1, 2021. 
 
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 laboratory service (81001) rendered by the out-of-network (OON) provider on 
November 1, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the transport chair provided on October 18, 2021. 
 
You asked the Plan to pay for the transport chair. You say that these services were referred by your in-network 
primary care physician (PCP). The Plan denied your request. The Plan says that the services were not approved 
in advance. 
 
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 durable medical equipment (DME) by a contract provider. The file does not show that 
the Plan provided notice that durable medical equipment (DME) would not be covered. Under Medicare rules, 
this means durable medical equipment (DME) is considered approved by the Plan. Therefore, we decided that 
the Plan has to pay for the transport chair provided on October 18, 2021.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specialty care transport service (A0434) and the ground 
mileage (A0425) rendered by the out-of-network (OON) provider on August 11, 2020. 
 
You asked the Plan to pay for this item/service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this item/service were 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 item/service 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 this item/service. Therefore, we decided that the Plan does not have to pay for the specialty care 
transport service (A0434) and the ground mileage (A0425) rendered by the out-of-network (OON) provider on 
August 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 3, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the patient presented to this provider for 
vaginal discharged after treatment by a provider. The Plan also says that lab work was performed, and patient 
was advised to follow up with the other provider. The Plan denied your request. The Plan says this provider is 
not a network provider with the Plan, and they have also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
 
 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 laboratory services provided on January 3, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for genetic testing provided on December 10, 
2021, to December 12, 2021. 
 
You asked the Plan to waive the copayments for genetic testing. You say that you did not know that your blood 
samples were being sent to this lab and not processed by the hospital. 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 $200 
copayment for in-network outpatient diagnostic tests, including genetic testing.  
 
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
the allowed amount of $161.70, which is less than the $200 copayment for genetic testing on December 10, 
2021. You have also been asked to pay the allowed amount of $183.15, which is less than the $200 copayment 
for genetic testing on December 12, 2021. You have been asked to pay a total of $344.85 ($161.70 copayment 
+ $183.15 copayment = $344.85). Genetic testing 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 copayments for genetic 
testing provided on December 10, 2021, to December 12, 2021.  
 
Your complaint about the testing not being processed by the hospital 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management services and a domiciliary rest 
home visit provided on September 8, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for chronic care management services and a domiciliary rest home visit. You say 
that this provider was not responsible to obtain authorization, and the assisted living facility is responsible to 
obtain prior authorization for all of their patients. The Plan denied your request. The Plan says this provider is 
out-of-network with the Plan, and authorization was not obtained 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 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 chronic care management services and a 
domiciliary rest home visit provided on September 8, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a ferric carboxymaltose injection and 
intravenous (IV) infusion provided on August 27, 2021, and September 3, 2021. 
 
You asked the Plan to waive the cost share for an injection and IV infusion. You say that you had no idea there 
would be any expense for the procedure. You also say you do not understand why the procedure was not 
covered completely. 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 Part B drugs. The Plan contract also says that enrollees must pay a $150 copayment for medical 
services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges. 
 
You have been asked to pay $169.95, which is 20% coinsurance of the allowed amount for each an injection on 
August 27, 2021, and September 3, 2021 ($849.75 allowed amount x 20% coinsurance = $169.95). An 
injection falls within the Medicare Part B Prescription Drugs benefit category.  
 
You have been asked to pay a $150 copayment for each IV infusion on August 27, 2021, and September 3, 
2021. You have been asked to pay a total of $639.90 ($169.95 coinsurance + $169.95 coinsurance + $150 
copayment + $150 copayment = $639.90). An IV infusion 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 cost share for a ferric carboxymaltose injection and intravenous (IV) 
infusion provided on August 27, 2021, and September 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic or therapeutic agent injections, paravertebral facet 
(zygapophyseal) joint (or nerves innervating that joint) and a triamcinolone acetonide injection provided on 
December 10, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for diagnostic or therapeutic agent injections, paravertebral facet (zygapophyseal) 
joint (or nerves innervating that joint) and a triamcinolone acetonide injection. You say that you are appealing 
with supporting records. The Plan denied your request. The Plan says the services were rendered by an out-of-
network provider, and the member does not have out-of-network benefits. The Plan also says that the member 
did not have an authorization on file. 
 
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 or therapeutic agent injections, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) and a triamcinolone acetonide 
injection provided on December 10, 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 (99213) rendered by the out-of-network 
(OON) provider on November 5, 2021. 
 
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 (99213) rendered by the out-of-network (OON) provider on  
November 5, 2021.