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

 
We decided that the Plan does not have to pay for physical therapy services provided on December 30, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for physical therapy services. You say that the rendering provider was not aware that 
the patient's provider is out of your network. 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 physical therapy services provided on December 
30, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound provided on September 23, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an ultrasound. 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 ultrasound provided on September 23, 2021 by 
an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SPECT test provided on August 2, 2021. 
 
You asked the Plan to waive the copayment for the SPECT test. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing 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 $5 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 You have been asked to pay a $5 copayment for the SPECT test. SPECT tests fall within the Outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for a SPECT test provided on August 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for removal of lens material provided on 
December 20, 2021. 
 
You asked the Plan to waive the copayment for removal of lens material. You say that you previously had 
cataract surgery and a piece was missed resulting in a second surgery. 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 $325 
copayment for each in-network outpatient surgery.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$325 copayment for the removal of lens material. The removal of lens material 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 removal of lens material provided on December 
20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam you had on December 29, 2021. 
 
You asked the Plan to pay for the oral exam. You say that you only had two oral exams in 2021. The Plan 
denied your request. The Plan says you had exhausted your oral exam benefit for 2021 prior to the services on 
December 29, 2021. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Your dental benefit covers one 
oral exam under your base dental benefits and one additional oral exam per calendar year under your optional 
supplemental dental benefits. Records show that you received (and the Plan paid for) oral exams on February 9, 
2021, and February 15, 2021.  Benefits for a third oral exam are not available under your dental benefits.  
 
 Therefore, we decided that the Plan does not have to pay for the oral exam you had on December 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services (A0425, 
A0427) provided on May 11, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation services. You say that the 
services should be covered as you disagree with the charges. The Plan denied your request. The Plan says the 
cost-sharing 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 $265 
copayment for Ambulance services.  
 
 
  You have been asked to pay a $265 copayment for ambulance transportation services. 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 transportation services (A0425, A0427) provided on May 
11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids you purchased from an out-of-network provider 
on December 13, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that it is your understanding that you have both in and 
out-of-network benefits. The Plan denied your request. The Plan says because you did not purchase these 
hearing aids from the designated vendor, they are not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from a network provider. You did not use a network provider. Therefore, we 
decided that the Plan does not have to pay for hearing aids you purchased from an out-of-network provider on 
December 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee fully meets criteria for IRF. The Plan 
denied your request. The Plan says the denial of authorization for IRF care is correct. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient rehab stay with an interdisciplinary approach to rehabilitation care.  While the enrollee may benefit from physical therapy, and/or occupational therapy, their rehab needs can be 
addressed at a low intensity alternate setting such as in an SNF or in-home with services. There is not a 
reasonable expectation that the enrollee would be able to fully participate in- and benefit from  the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
February 9, 2022, to February 10, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing 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 $250 
copayment per admission for inpatient hospital care.  
 
 
  You have been asked to pay a $250 copayment for the inpatient hospital stay. 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 inpatient hospital stay provided from February 9, 2022, to February 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for inpatient hospital and inpatient mental 
health care provided from July 29, 2021, to August 19, 2021. 
 
You asked the Plan to waive the copayments for the inpatient and inpatient mental health care. You say that 
you did not have control over being assigned a private room. You say that you should not be responsible for 
incorrect billing. 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 $345 per 
day for days 1-5 and $0 per day for additional days for each inpatient admission. 
 
Your contract with the Plan also clearly says that you must pay $345 per day for days 1-5 and $0 per day for 
additional days for each inpatient mental health admission. 
 
The file shows that you were under inpatient care status from July 29, 2021, to August 1, 2021. You have been 
asked to pay $345 per day for the first 3 days of inpatient care, for a total of $1,035. The inpatient care falls 
within the Inpatient Hospital Care benefit category. The file also shows that you were transferred to mental 
health care from August 2, 2021, to August 6, 2021. This transfer is considered a new admission. Therefore, 
you have been asked to pay $345 per day for the first 4 days of inpatient mental health care (there is no 
copayment for the discharge date), however the Plan reprocessed this claim later showing a responsibility of 
only $690. The file also shows another inpatient mental health stay from August 12, 2021, to August 19, 2021. 
During the processing of this claim, you had met your maximum out-of-pocket (MOOP) expenses for the year. 
Therefore, the charges for this stay applied the remaining $1,294.67 to reach your MOOP of $4,700. The 
inpatient mental health care 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 copayments for inpatient hospital and inpatient mental health care provided from 
July 29, 2021, to August 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the enteral supplies (B9998) rendered by the out-of-network 
(OON) provider from May 26, 2021, through June 25, 2021. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says the items 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 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 the enteral supplies (B9998) rendered by the out-of-network (OON) provider from May 26, 
2021, through June 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 18, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on June 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a daratumumab injection (J9144) provided 
on October 13, 2021. 
 
You asked the Plan to waive the coinsurance for the daratumumab injection. You say that the services 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 Medicare Part B prescription drugs, and the administration of them.  
 
 
  You have been asked to pay a 20% coinsurance for the daratumumab injection (allowed amount is $8,117.64 x 
20% = $1,623.53). Daratumumab injections fall 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 a daratumumab injection (J9144) provided on October 13, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy (EGD) 
with biopsy performed on January 13, 2022. 
 
You asked the Plan to waive the copayment for the EGD with biopsy. You say that you were not aware of the 
charges for this procedure. 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 $350 
copayment per day for outpatient procedures and services, including endoscopies.  
 
You have been asked to pay a $350 copayment for the EGD with biopsy. The EGD with 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 an 
esophagogastroduodenoscopy (EGD) with biopsy performed on January 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a magnetic resonance imaging (MRI) of 
the pelvis provided on January 17, 2022. 
 
You asked the Plan to waive the coinsurance for the MRI. You say that the imaging was ordered by your doctor 
and should be covered. The Plan denied your request. The Plan says the correct coinsurance 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 20% 
coinsurance for diagnostic radiology services, including MRI's.  
 
You have been asked to pay $79.67, which is 20% of the allowed amount for the MRI ($398.34 allowed 
amount x 20% coinsurance = $79.67). The MRI 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 a magnetic 
resonance imaging (MRI) of the pelvis provided on January 17, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
from August 4, 2021, to August 30, 2021. 
 
You asked the Plan to waive the copayment for the SNF care. You say that you were told that you were 
charged for the last two days as a result of being moved to a different room. You say that this did not happen. 
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 $0 per 
day for days 1-20, $184 per day for days 21-47, and $0 per day for additional days for each benefit period.  
 
The file shows that you were in the skilled nursing facility from August 4, 2021, to August 30, 2021. Therefore, you have been asked to pay $184 per day for days 21-26 of SNF care. The total for the stay is 
$1,104 ($184 copayment x 6 days = $1,104). The file does not show evidence of additional charges for moving 
to a different room. The SNF care falls within the Skilled Nursing Facility (SNF) Care benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided from August 4, 
2021, to August 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for IV infusion therapy (96360) provided 
September 20, 2021. 
 
You asked the Plan to waive the copayment for the IV infusion therapy. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing 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 $370 
copayment for Hospital Outpatient Facilities and Ambulatory Surgical Centers.  
 
 You have been asked to pay a $236.14 copayment for the IV infusion therapy, which is less than the standard 
$370. IV infusion therapy falls within the 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 IV infusion therapy (96360) 
provided September 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full mouth debridement to enable comprehensive oral 
evaluation and diagnosis (D4355) provided on December 22, 2021. 
 
You asked the Plan to pay for the dental service. You say that you have a $2,000 dental benefit. You say you 
are allowed 2 cleanings per year. You say that you do not understand why this extreme cleaning was not 
covered. You say that it was necessary to save your teeth. You also say that this should be paid. The Plan 
denied your request. The Plan says full mouth debridement is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the full mouth debridement is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the full 
mouth debridement to enable comprehensive oral evaluation and diagnosis (D4355) provided on December 22, 
2021.