Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 31, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network 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 an office visit provided on July 31, 2022, 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 subsequent nursing facility care services provided on 
April 19, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility care services. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 subsequent nursing facility care services 
provided on April 19, 2022, 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 the ambulance services (A0425, A0428), 
provided on September 1, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that there should not be a 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $290 copayment for ambulance services.  
 
The enrollee has been asked to pay $277.06 out of the $290 copayment for the ambulance services. This 
service falls within the ambulance services 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 the ambulance services (A0425, A0428), provided on September 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services (90834) provided on July 26, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
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 psychotherapy services (90834) provided on July 
26, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 27, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
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 July 27, 2021, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on April 29, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that you would like to request reconsideration for payment. 
The Plan denied your request. The Plan says the provider is out-of-network, and it was determined these 
services can be received in-network. 
 
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 drug testing provided on April 29, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 31, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network 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 an office visit provided on May 31, 2022, 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 provided on July 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services received are not a covered benefit. 
 
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 visit provided on July 11, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient observation on June 30, 2022, to 
July 01, 2022. 
 
You asked the Plan to waive the copayment for outpatient observation. You say that you want to appeal the 
amount being charged. 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 $350 
copayment per visit for Medicare-covered outpatient observation services. Observation services are hospital 
outpatient services given to determine if you need to be admitted as an inpatient or can be discharged. 
 
You have been asked to pay a $350 copayment for outpatient observation. This item/service falls within the 
Outpatient hospital observation 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 
outpatient observation on June 30, 2022, to July 01, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vitamin D testing provided on August 13, 2020. 
 
You asked the Plan to pay for the vitamin D testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the claim was submitted untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the vitamin D testing was not filed until June 9, 2020. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the vitamin D testing provided on August 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision services (99999, V2781, V2020) provided on May 25, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the vision services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says there were network providers available. 
 
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 at issue in this appeal. The Plan did not pre-approve the items at 
issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the 
Plan does not have to pay for vision services (99999, V2781, V2020) provided on May 25, 2022, by an out-of-
network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on July 24, 2022. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit 
exists between 74176 and 72192. This PTP edit has a modifier indicator of 1, which indicates modifiers 
associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, this claim cannot be paid due to the 
omission of a required modifier. Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for imaging services provided to the enrollee on July 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a podiatry office visit and an x-ray 
provided on June 1, 2022. 
 
You asked the Plan to waive the copayment for a podiatry office visit and an x-ray. You say that you are 
appealing 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 $35 
copayment for in-network podiatry services and a $10 copayment for an in-network outpatient diagnostic 
tests/x-ray services.  
 
You have been asked to pay a $35 copayment for a podiatry office visit and a $10 copayment and an x-ray. The 
total amount you are being asked to pay is $45 ($35 + $10 =$45). 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 podiatry office visit and an x-ray provided on June 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 7, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the home POS code. 
The records do not support that the sample was taken in a skilled nursing facility setting. Therefore, we decided 
that the Plan does not have to pay for lab services provided on March 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out of network laboratory services 
provided on May 03, 2022. 
 
You asked the Plan to waive the coinsurance for out of network laboratory services. You say that you werent 
aware you would have such a high 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 50% 
coinsurance for Laboratory services in an outpatient hospital facility. 
 
You have been asked to pay 50% coinsurance for out of network laboratory services. This item/service falls 
within the Laboratory services in an outpatient hospital facility 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 out of network laboratory services provided on May 03, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit and laboratory services 
provided on May 16, 2022. 
 
You asked the Plan to waive the deductible for an office visit and lab services. You say that this should be 
covered. 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. Your 
contract with the Plan says that there is $500 deductible which applies to office visit and lab services. 
 
The item or service you asked the Plan to waive 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 $500 deductible which applies to office visit and lab services. This cost 
sharing is a contractual obligation that had not been met at the time an office visit and lab services was received 
on May 16, 2022. Therefore, we decided that the Plan does not have to waive the deductible for an office visit 
and laboratory services provided on May 16, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on November 12, 2021. 
 
You asked the Plan to pay for the laboratory services. 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. 
 
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. 
 
The enrollee was referred for the laboratory services by a contract provider. The file does not show that the 
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on November 12, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, an intralesional injection, and a triamcinolone 
acetonide injection provided on March 2, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit, an intralesional injection, and a triamcinolone acetonide injection. 
You say that your state provides for direct patient access for dermatological services, up to five visits within a 
twelve month period without a prior authorization. The Plan denied your request. The Plan says services from 
non-participating providers are not covered under the Plan unless preauthorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit, an intralesional injection, and a 
triamcinolone acetonide injection provided on March 2, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 5, 2022. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that medical documentation 
substantiates the need for the services, supplies and medical necessity. The Plan denied your request. The Plan 
says the out-of-network services were not authorized.  
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for subsequent nursing facility care provided on July 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the injection (J7328), provided on June 2, 
2022, through July 14, 2022. 
 
You asked the Plan to waive the coinsurance for the injection. You say that the cost share is wrong. 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% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for the injection. This item/service falls within the Medicare 
Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the 
injection (J7328), provided on June 2, 2022, through July 14, 2022.