Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for mental health services provided from 
January 12, 2022, to February 22, 2022. 
 
You asked the Plan to waive the copayment for mental health services. You say that since these were telehealth 
visits, they should be covered. The Plan denied your request. The Plan says the deductible amounts have been 
waived and you will only be responsible for a $35 copayment for each date of service. The Plan says the 
copayment 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 $40 
copayment for physician specialist services (including surgery second opinion, telehealth services, home 
infusion professional services, and urgently needed services).  
You have been asked to pay $35 copayment for each mental health visit, which is less than the standard $40 
copayment. Telehealth services fall 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 copayment for mental health services provided 
from January 12, 2022, to February 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist telehealth visit provided by a 
network practitioner on February 4, 2022. 
 
You asked the Plan to waive the copayment for the specialist telehealth visit. You say that you do not believe 
you should pay a $45 copayment for a quick, follow-up visit. The Plan denied your request. The Plan says you 
have been asked to pay 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 $45 
copayment for each in-network specialist telehealth visit.  
 
 You have been asked to pay a $45 copayment for the specialist telehealth visit. The specialist telehealth 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 copayment for the specialist telehealth visit provided by a network practitioner on 
February 4, 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 
February 17, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you were given 
misinformation about the provider being in-network. 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 $45 
copayment for a specialist office visit.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$45 copayment for a specialist office visit. A specialist 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 copayment 
for a specialist office visit provided on February 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient office visit provided on August 30, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient office visit. You say that you have been trying to resolve the bill 
and would like for the Plan to cover it. The Plan denied your request. The Plan says the rendering provider is an 
OON provider and there was no referral or an approved authorization on file. 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 an outpatient office visit provided on August 30, 
2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient procedure provided on 
November 26, 2021. 
 
You asked the Plan to waive the copayment for outpatient procedure. You say that you don't understand where 
the copayment is coming from and that the amount is too much. The Plan denied your request. The Plan says 
the copayment 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 $300 
copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient 
facility. 
 
 
 You have been asked to pay a $300 copayment for an outpatient procedure. The outpatient procedure 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 outpatient procedure 
provided on November 26, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
December 8, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you are enrolled in 
the Plan's financial assistance program and should be reimbursed. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment per one-way ambulance trip.  
 
You have been asked to pay a $200 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance Services benefit category. Please note that the financial assistance program only covers services from the Plans providers. In this case, the ambulance company is not included. 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 provided on December 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office consultation to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve an office consultation. You say that you believe that you would best benefit 
from this provider's experience with the preoperative patient 3D plan for x-rays and diagnosis, on through his 
completion of a higher degree of accuracy in surgery as a result of his guided use of this devise technique. The 
Plan denied your request. The Plan says there are 2 available in-network providers who also used this device. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  
 
 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office consultation to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a biopsy of the tongue provided on 
December 15, 2021. 
 
You asked the Plan to waive the copayment for a biopsy of the tongue. You say that although a biopsy was 
done surgery was not performed so you should not be charged. The Plan denied your request. The Plan says the 
copayment 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 $150 
copayment for Medicare-covered surgery or other services at an outpatient hospital or ambulatory surgical 
centers.  
 You have been asked to pay $150 copayment for a tongue biopsy. The tongue biopsy falls within the 
Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers benefit category. The tongue biopsy is considered a surgical procedure. 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 biopsy of the tongue provided on December 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an outpatient office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the outpatient office visit. You say that a referral with medical documents 
were sent to review. The Plan denied your request. The Plan says there was no specific reason given why an 
OON provider was needed to be seen. Also, there are multiple in-network providers that can provide the same 
quality 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an outpatient office visit to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the revision of total hip arthroplasty to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the revision of total hip arthroplasty. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says since there are in-network providers that can 
offer the same care, this request is denied. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the revision of total hip arthroplasty to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the endocrinology office visits to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the endocrinology office visits. You say that you would like to continue to 
see the OON provider. The Plan denied your request. The Plan says they approved 1 visit with the OON 
provider which will allow the enrollee to transition care to an in-network provider. The Plan also says that the 
enrollee can see an in-network provider without prior authorization and has provided a list of in-network 
providers that provide the same quality 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the endocrinology office visits to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve unlisted evaluation and management service, and 
strabismus surgery, recession or resection procedure to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve unlisted evaluation and management service, and strabismus surgery, 
recession or resection procedure. You say that there are not any pediatric ophthalmologists on the Plan 
network, and a pediatric ophthalmologist is the appropriate provider for this service. The Plan denied your 
request. The Plan says there are in-network provider(s) and facilities within a reasonable distance from your 
location that can provide this 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
unlisted evaluation and management service, and strabismus surgery, recession or resection procedure to be 
provided by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $70 copayment for emergency room services provided on 
January 9, 2022. 
 
You asked the Plan to waive the $70 copayment for emergency room services provided on January 9, 2022. 
You say that on January 9, 2022, you went to the San Francisco General Hospital when you had fluid on your 
knee; but while there, there wasn't any care at all. You also say you were sent home with the IV in your hand 
and returned to the emergency room within a half an hour because you had two wires in your hand and were 
told you would not be billed. The Plan denied your request. The Plan says enrollees pay a $70 copayment for 
emergency room services 
 
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 $70 
copayment for emergency room services.  
 
 You have been asked to pay $70 copayment for emergency room services. Emergency room services fall 
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 $70 copayment for 
emergency room services provided on January 9, 2022. 
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided from November 
1, 2021 to November 26, 2021. 
 
You asked the Plan to waive the copayment for physical therapy. You say that it was your understanding that 
the out-of-pocket cost to you would be $15 per treatment at a stand-alone facility. The Plan denied your 
request. The Plan says you have been charged the correct copayment 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 $40 
copayment for physical therapy at an in-network outpatient hospital.  
 
 
 
 
 
 You have been asked to pay a total of $480 for physical therapy ($40/visit x 12 visits = $480).  Physical 
therapy falls within the Outpatient rehabilitation 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 physical therapy provided from November 1, 2021 to November 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to fully reimburse for the durable medical equipment (DME) provided 
on October 18, 2021. 
 
You asked the Plan to fully reimburse for the DME. You say that you were out of town and needed the DME 
and it was medically necessary to get the supplies. The Plan partially denied your request. The Plan says they 
reprocessed the claim using the applicable out-of-network benefits with a partial reimbursement. Therefore, the 
proper coinsurance for out-of-network benefits will be 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 35% 
coinsurance for out-of-network Medicare-covered items. 
 
  You have been asked to pay a 35% coinsurance for the DME. The DME falls within Durable medical 
equipment (DME) and related supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to fully reimburse for the 
durable medical equipment (DME) provided on October 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the urology consultation to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the urology office visit. You say that the out-of-network doctor would have 
a permanent solution for your condition and improve your quality of life. The Plan denied your request. The 
Plan says the provider is out-of-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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the urology consultation in this appeal. We found no exception that would require 
the Plan to pre-approve the urology consultation. Therefore, we decided that the Plan does not have to pre-
approve the urology consultation to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for shipping and handling charges for contact lenses 
provided on October 27, 2021. 
 
You asked the Plan to reimburse you for shipping and handling charges for contact lenses. You say that you 
feel that shipping and handling are part of the total cost of purchasing products these days online and should be 
considered a normal and necessary expense in addition to the actual product itself. The Plan denied your 
request. The Plan says shipping and handling is not a Medicare reimbursable service or supply, as it is not a 
medical service or item. Sales tax, handling, and shipping are not medical services or charges. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that shipping and handling are not a covered benefit. 
Therefore, we decided that the Plan does not have to reimburse you for shipping and handling charges for 
contact lenses provided on October 27, 2021.