Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Skilled Nursing Facility Services on June 11, 2021 to June 
25, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Skilled Nursing Facility Services. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says prior authorization is required for 
Skilled Nursing Facility 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 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 Skilled Nursing Facility Services on June 11, 2021 
to June 25, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the deductible for a magnetic resonance imaging (MRI) of the 
shoulder provided on October 5, 2021. 
 
You asked the Plan to reduce the deductible for an MRI. You say that you would like the insurance company to 
pay their part. You also say you would like the insurance company to explain their claims. 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. Your 
contract with the Plan says that there is $1,000 deductible which applies to in-network radiological diagnostic 
services, including MRIs at a free-standing facility.  
 
 The record shows the claim was processed correctly, as your deductible had not been met. The item or service 
you asked the Plan to reduce the deductible for falls within the Outpatient Diagnostic Tests and Therapeutic 
Services and Supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is $1,000 deductible which applies to in-network radiological diagnostic services, including 
MRIs at a free-standing facility. This cost sharing is a contractual obligation that had not been met at the time 
an MRI was received on October 5, 2021. Therefore, we decided that the Plan does not have to reduce the 
deductible for a magnetic resonance imaging (MRI) of the shoulder provided on October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit (99335) provided on 
November 1, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that since the member was in a nursing 
facility, the doctor was not responsible to get authorization. You also say that the nursing home is responsible 
to obtain prior authorization for their patients, which should cover medical treatments by the provider. 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 a domiciliary or rest home visit (99335) provided 
on November 1, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for bevacizumab (Avastin) injections 
provided from March 18, 2021, to November 9, 2021. We also decided that the Plan does not have to waive the 
copayments for an eye exam and a diagnostic eye test provided on November 9, 2021. 
 You asked the Plan to waive the coinsurance and copayments for the injections, eye exam, and diagnostic test. 
You say that you would like the Plan to settle the bill. The Plan denied your request. The Plan says the correct 
coinsurance and copayments were applied. 
 
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 Part B chemotherapy drugs. 
 
Your contract with the Plan also clearly says that you must pay a $5 copayment for each exam to diagnose and 
treat conditions of the eye. 
 
Your contract with the Plan also clearly says that you must pay up to a $50 copayment for diagnostic radiology 
services in an office setting or imaging center. 
 
Drug/Service Allowed Amount Coinsurance/Copayment 
Avastin  March 18, 2021 $375.80 $75.16 
Avastin  May 6, 2021 $375.80 $75.16 
Avastin  November 9, 2021 $352.05 $70.41 
Eye Exam  November 9, 2021 - $5.00 
Diagnostic Eye Test  November 9, 2021 - $45.00 
Total:  $270.73 
 
You have been asked to pay $270.73 for the injections, eye exam, and diagnostic test. The injections fall within 
the Medicare Part B Prescription Drugs benefit category. The eye exam falls within the Vision Care benefit 
category. The diagnostic test 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 coinsurance for bevacizumab (Avastin) 
injections provided from March 18, 2021, to November 9, 2021. We also decided that the Plan does not have to 
waive the copayments for an eye exam and a diagnostic eye test provided on November 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a tangential skin biopsy provided on 
January 5, 2022. 
 
You asked the Plan to waive the copayment for a tangential skin biopsy. You say that you were unaware that 
the procedure you received was considered a surgical service. 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 $125 
copayment for outpatient surgery.  
 
You have been asked to pay a $125 copayment for a tangential skin biopsy. A tangential skin biopsy falls 
within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a tangential skin 
biopsy provided on January 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rest home visit provided on November 17, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the rest home visit. You say that the facility is responsible for obtaining prior 
authorization. The Plan denied your request. The Plan says the services were provided out-of-network and were 
not 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 the rest home visit provided on November 17, 
2021, by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a therapeutic procedure (97110) provided on May 19, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a therapeutic procedure. You say that another claim for a different date of service 
for the same procedure was partially paid. 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. You also say 
that the referring provider was out-of-network with the Plan, and the services rendered were not Plan directed 
care.  
 The Plan also says that regarding the appellant's statement that the Plan paid for similar services rendered on 
May 19, 2021, they reviewed their records and determined that the claim for services rendered on May 19, 
2021, was denied for no authorization, which is now being appealed, and there is no record of a paid claim for 
May 17, 2021. 
 
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 therapeutic procedure (97110) provided on May 
19, 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 services provided on September 22, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the office services. You say that the provider is a participating provider and does 
not require a referral. Also, service was rendered to the enrollee out of medical necessity. The Plan denied your 
request. The Plan says the rendering provider is an out-of-network provider and there was no referral from an 
in-network provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office services provided on September 22, 
2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular pathology testing provided to the enrollee on May 
24, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says a panel constitutes a single procedural service, so one CPT code must be submitted for 
the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for molecular pathology testing provided to the enrollee on May 24, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility (SNF) stay provided from January 
1, 2021, to January 28, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the SNF stay. You say that you would like the claim to be reprocessed for 
payment. The Plan denied your request. The Plan says the rendering provider is an out-of-network provider and 
there was no approved authorization for the dates of service. 
  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a skilled nursing facility (SNF) stay provided from 
January 1, 2021, to January 28, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on  
July 1, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transport. The Plan denied your request. The 
Plan says there is a $275 copay for each one-way Medicare-covered ambulance transport. 
 
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 $275 
copayment for Ambulance Services.  
 
You have been asked to pay a $222.32 copayment for the ambulance transport. The ambulance transport falls 
within the Ambulance 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 
ambulance transport provided on July 1, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hospital observation care provided from 
October 16, 2021, to October 19, 2021. 
 
You asked the Plan to waive the copayment for the hospital observation care. You say that the enrollee should 
not be obligated to pay for the care since he should have received the proper care months ago. The Plan denied 
your request. The Plan says the enrollee has 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $125 copayment for each outpatient hospital facility visit for observation care.  
 
The enrollee has been asked to pay a $125 copayment for the hospital observation care. The hospital 
observation care falls within the Outpatient Hospital Observation benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for hospital observation care provided from October 16, 2021, to October 19, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to lower the copayment for a specialist telehealth visit provided on 
December 1, 2021. 
 
You asked the Plan to lower the copayment for the specialist telehealth visit. You say that the appointment was 
a follow-up appointment and you only spoke to the provider for a couple of minutes. The Plan denied your 
request. The Plan says documentation received confirmed a specialist visit took place on the date of service. 
Therefore, the proper copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for each covered telehealth visit or consultation in an outpatient location with a specialist.  
 You have been asked to pay a $40 copayment for the specialist telehealth visit. The specialist telehealth visit 
falls within 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 lower the copayment for a specialist telehealth visit provided on December 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the office visit on September 22, 2021. 
 
You asked the Plan to waive the coinsurance for the office visit. You say that you should not be responsible for 
this coinsurance. The Plan denied your request. The Plan says the coinsurance applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a 35% 
coinsurance for primary care visits with out-of-network providers.  
 
 
 
 
 You have been asked to pay a $38.91 coinsurance for the office visit ($111.16 allowed amount x 35%). The 
office visit falls within the Physician/Practitioner services, including doctors office visits benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for the office visit on September 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on September 7, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for out-of-network office visit. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says prior authorization is required for an 
out-of-network office visit. 
 
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 office visit provided on September 7, 2021 by an 
out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychiatric encounter provided on November 18, 2021, by an 
OON provider. 
 
You asked the Plan to pay for psychiatric encounter. You say that the nursing home staff requested you to 
address a documented medical issue that requires a mental status examination for routine psychotropic(s) 
medication. The Plan denied your request. The Plan says the services were provided out-of-network and were 
not 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 psychiatric encounter provided on November 18, 
2021, by an OON provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an emergency room visit provided from 
November 13, 2021, to November 25, 2021. 
 
You asked the Plan to waive the copayments for emergency room visits. You say that you were admitted as an 
inpatient to the hospital. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. The Plan also says that no claims were received for an inpatient admission for the two dates of 
service in questions. 
 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 $110 
copayment for each emergency room visit. The Plan contract also says that if you are held for observation, the 
$110 copayment per visit still applies. 
 
The record shows even if you were held for observation the $110 copayment per visit still applies. You have 
been asked to pay a total of $220, which is a $110 copayment for each emergency room visit ($110 copayment 
+ $110 copayment = $220). An emergency room visit falls within the Emergency 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 copayments for an emergency room visit provided from November 13, 
2021, to November 25, 2021.