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

 
We decided that the Plan does not have to waive the copayment for SNF services provided from August 13, 
2021, to August 30, 2021. 
 
You asked the Plan to waive the copayment for SNF services. You say that you received a bill for services 
rendered over a year ago and it would be difficult for you to pay it. 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 $0 
copayment for days 1 to 20, a $184 copayment for days 21 to 57, and $0 copayment for up to 100 days for 
Medicare-covered SNF services.  
 
 
  You have been asked to pay a $2,024 copayment for SNF services ($184 per day x 11 days = $2,024). 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 SNF services provided from August 13, 2021, to August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home, or custodial care visit (code 99336) 
provided on November 23, 2022 
 
You asked the Plan to pay for the domiciliary, rest home, or custodial care visit. You say that it is the assisted 
living facilitys responsibility to obtain prior authorization for all of their patients. The Plan denied your 
request. The Plan says 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 Plan says that the Plan has 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 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 a domiciliary, rest home, or custodial care visit (code 99336) 
provided on November 23, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on June 28, 2022. 
 
You asked the Plan to pay for a domiciliary or rest home visit. The Plan denied your request. The Plan says 
Original Medicare is responsible for payment. 
   
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 a domiciliary or rest home visit provided on June 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for telehealth services provided on November 
28, 2022. 
 
You asked the Plan to reduce the copayment for telehealth services. You say that you are getting a discount 
from the hospital and is requesting to reduce 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 $45 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $45 copayment for telehealth services. 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 reduce the copayment for telehealth services provided on November 28, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paramedic intercept services provided on September 26, 
2022. 
 
You asked the Plan to pay for paramedic intercept services. You say that you would like reconsideration 
because the requested paramedic intercept services are medically necessary. The Plan denied your request. The 
Plan says the requested paramedic intercept services are not a covered benefit. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for paramedic 
intercept services provided on September 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy (EGD) 
with biopsy provided on August 12, 2021. 
 
You asked the Plan to waive the copayment for an esophagogastroduodenoscopy (EGD) with biopsy. You say 
that you think that this service should be covered in full. 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 $175 
copayment for Medicare-covered surgery or other services provided at an outpatient hospital. 
 
You have been asked to pay a $175 copayment for an esophagogastroduodenoscopy (EGD) with biopsy. This 
item/service falls within the Medicare-covered surgery or other services provided at an outpatient hospital 
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 esophagogastroduodenoscopy 
(EGD) with biopsy provided on August 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on June 28, 2022. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that the Plan 
should cover the CT scan without charging a 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 $165 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $165 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic test 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. The total you owe is $164.43, which is less than the standard $165 copayment 
for a CT scan. Therefore, we decided that the Plan does not have to waive the copayment for a computed 
tomography (CT) scan provided on June 28, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for medication assisted treatment; methadone (G2067) provided on 
November 7, 2022. 
 
You asked the Plan to pay for medication assisted treatment; methadone. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered. 
 
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 facility where the provider rendered the services is enrolled with Medicare 
as an OTP. The OTP is the billing provider and is Substance Abuse and Mental Health Services Administration 
(SAMHSA) certified. The rules cited by the Plan do not provide a valid reason to deny this claim given that the 
OTP meets the Medicare coverage criteria. Therefore, we decided that the Plan has to pay for medication 
assisted treatment; methadone (G2067) provided on November 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit provided on December 07, 
2022. 
 
You asked the Plan to waive the deductible for an office visit. You say that you disagree with the cost share. 
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 $1,700 
deductible for doctor and other health care provider services. 
 
You have been asked to pay a $1,700 deductible for an office visit. This item/service falls within the doctor and 
other health care provider 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 deductible for an 
office visit provided on December 07, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient mental health visit provided on August 03, 
2022. 
 
You asked the Plan to pay for an outpatient mental health visit. You say that the records attached support the 
services provided. 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 outpatient mental 
health visit provided on August 03, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on August 18, 2022. 
 
You asked the Plan to pay for physical therapy. You say that no prior authorization is 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 physical therapy 
provided on August 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 12, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
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 office visit provided 
on December 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 28, 2022. 
 
You asked the Plan to pay for an office visit. You say that it is the responsibility of the facility to obtain 
referrals. 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 office visit provided 
on February 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99204, 74230, 72040, 70100, 70310, and 
74240 provided on November 3, 2022. 
 
You asked the Plan to pay for procedure codes 99204, 74230, 72040, 70100, 70310, and 74240. You say that 
you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that for mobile units serving an entity with its own POS 
code, the entity's POS code should be reported. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the office visit and imaging services have not been met. The documentation supports that the 
enrollee was at a skilled nursing facility on the date of service. As such, the use of the office POS code is not appropriate. Therefore, we decided that the Plan does not have to pay for procedure codes 99204, 74230, 
72040, 70100, 70310, and 74240 provided on November 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 03, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
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 office visit provided 
on October 03, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
December 20, 2022. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that the provider did not 
provide adequate treatment and you needed to go to another provider for additional services. The Plan denied 
your request. The Plan says the cost sharing will be applied according to the Plan contract. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for a specialist office visit.  
 
You have been asked to pay a $30 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner 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 a 
specialist office visit provided on December 20, 2022.  
 Your complaint about needing to see another provider for additional services 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on June 
21, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you were told to ignore 
this bill. 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 $250 
copayment for in-network ambulance services. 
 
You have been asked to pay a $250 copayment for the ambulance services. This item/service falls within the 
in-network 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. According to the EOC, a $250 copayment applies for each ground ambulance 
service. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance services 
provided on June 21, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit, and related services provided 
on July 16, 2022. 
 
You asked the Plan to pay for an emergency department visit and related services. The Plan denied your 
request. The Plan says Original Medicare is responsible for payment. 
   
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 an emergency department visit, and related services provided 
on July 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on January 11, 2023. 
 
You asked the Plan to pay for telehealth services. You say that the records attached support the services 
provided. 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 telehealth services 
provided on January 11, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on December 16, 2022. 
 
You asked the Plan to pay for nursing facility care. You say that you are appealing with supporting records. 
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 nursing facility care 
provided on December 16, 2022.