Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for oxygen equipment provided on June 29, 
2023. 
 
You asked the Plan to waive the coinsurance for oxygen equipment. You say that you say that you are not 
going to pay for something the plan should be paying for. 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 20% 
coinsurance for durable medical equipment (DME) and related supplies. 
 
You have been asked to pay 20% coinsurance for oxygen equipment. This item/service falls within the 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. The total you owe is $47.84 ($239.18 allowed amount x 20% = 
$47.84). Therefore, we decided that the Plan does not have to waive the coinsurance for oxygen equipment 
provided on June 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network dermatology visit provided 
on June 21, 2023. 
 
You asked the Plan to waive the copayment for an in-network dermatology visit. You say that you never had 
any any skin lesions or removals. 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 Physician/Practitioner services, including doctors office visits. 
 
You have been asked to pay a $35 copayment for an in-network dermatology visit. 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 waive the copayment for an in-network dermatology visit provided on June 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit on May 24, 2023.  
 
You asked the Plan to waive the deductible for an office visit. You say that you are requesting reconsideration 
for the service. 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 a $680 deductible which applies to physician/practitioner services, 
including doctor's office visits.  
 
The item or service you asked the Plan to waive the deductible for falls within the physician/practitioner 
services, including doctor's office visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $680 deductible which applies to physician/practitioner services, 
including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time an 
office visit was received on May 24, 2023. Therefore, we decided that the Plan does not have to waive the 
deductible for an office visit on May 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on February 9, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the nursing facility care. You say that the services were provided in a nursing 
home. The Plan denied your request. The Plan says enrollees must receive their care from a network provider. 
 
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 item/service 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 this item/service. Therefore, 
we decided that the Plan does not have to pay for the subsequent nursing facility care provided on February 9, 
2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames (V2020) and bifocal, sphere lenses (V2200) provided 
on May 24, 2023.  
You asked the Plan to pay for frames (V2020) and bifocal, sphere lenses (V2200). You say that you were told 
word for word to go ahead and order glasses because it would be your responsibility after cataract surgery. You 
also say you were not advised of the correct process for getting basic cataract glasses. The Plan denied your 
request. The Plan says you must use network providers to get your medical care and services. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when you use an in-network provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that you must use network providers to get your 
medical care and services. Based on this information, we decided that the Plan's rules for coverage of frames 
(V2020) and bifocal, sphere lenses (V2200) have not been met. Therefore, we decided that the Plan does not 
have to pay for frames (V2020) and bifocal, sphere lenses (V2200) provided on May 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for hearing aids provided on April 26, 2023. 
 
You asked the Plan to reimburse for hearing aids. You say that customer services, whom you spoke with, said 
you need a referral for a hearing aid test and purchase of hearing aids from this provider. The Plan denied your 
request. The Plan says the service sought or obtained by you was rendered by a provider who is not under 
contract with the Plan. 
 
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 they are obtained through an in-network hearing provider. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse for 
hearing aids provided on April 26, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided by an 
out-of-network provider from March 30, 2023, to April 3, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you cannot afford 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 $295 
copayment per day, days 1 to 5, for out-of-network inpatient hospital care. 
 
 You have been asked to pay a $1180 copayment for the inpatient hospital stay ($295 copayment x 4 days = 
$1180). This item/service falls within the inpatient hospital 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 the inpatient hospital stay provided by an out-of-network provider from March 30, 
2023, to April 3, 2023.
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 06, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you were not 
expecting such a high copayment for the service received. 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 $325 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $325 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic tests 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 
computed tomography (CT) scan provided on June 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out-of-network physical therapy services 
provided on May 08, 2023, to May 25, 2023. 
 
You asked the Plan to waive the coinsurance for out-of-network physical therapy services. You say that you 
were not aware that this provider was out-of-network, and you cannot afford this large coinsurance amount. 
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 40% 
coinsurance for Provider and Professional Services. 
 
You have been asked to pay 40% coinsurance for out-of-network physical therapy services. This item/service 
falls within the Provider and Professional 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. The total you owe is $156.61 for the above dates of service 
($59.58 + $22.03 + $30.94 + $22.03 + $22.03 = $156.61). Therefore, we decided that the Plan does not have to 
waive the coinsurance for out-of-network physical therapy services provided on May 08, 2023, to May 25, 
2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy with biopsy provided on 
April 26, 2023. 
 
You asked the Plan to waive the copayment for a colonoscopy with biopsy. You say that you were advised this 
was a routine colonoscopy. 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 $200 
copayment for in-network surgery performed in an outpatient hospital setting. 
 
You have been asked to pay a $200 copayment for a colonoscopy with biopsy. This item/service falls within 
the in-network surgery performed in an outpatient hospital setting 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 colonoscopy with biopsy provided on April 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection performed in an outpatient 
hospital provided on May 31, 2023. 
 
You asked the Plan to waive the copayment for an injection performed in an outpatient hospital. You say that 
you feel the copayment for the injection should be waived. 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 $150 
copayment for outpatient surgery. 
 
You have been asked to pay a $150 copayment for an injection performed in an outpatient hospital. This 
item/service falls within the outpatient surgery 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 injection performed in an outpatient hospital provided on May 31, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital stay provided on June 04, 2023. 
 
You asked the Plan to pay for inpatient hospital stay. You say that you are requesting reconsideration for the 
service 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 inpatient hospital stay 
provided on June 04, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a drug test provided on March 27, 2023. 
 
You asked the Plan to pay for a drug test. You say that you are requesting reconsideration of the denied claim. 
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 a drug test provided on 
March 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network otolaryngology telehealth 
visit provided on June 19, 2023. 
 
You asked the Plan to waive the copayment for an in-network otolaryngology telehealth visit. You say that this 
was just a phone call, no one should have to pay this much, or at all, for a phone call. 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 $40 
copayment for a specialist office visit. 
 
You have been asked to pay a $40 copayment for an in-network otolaryngology telehealth visit. This 
item/service falls within the a specialist office visit 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 in-network otolaryngology telehealth visit provided on June 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on May 26, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the home visit. You say that you are appealing the denial with supporting 
documentation. The Plan denied your request. The Plan says the service was not authorized. 
 
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 home visit provided on May 26, 2023, by an 
OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frame (V2025), progressive lenses (V2781), photochromatic 
lenses (V2744), high index lenses (V2782), deluxe lenses (V2702), and vision supplies/accessories (V2797) 
provided on June 1, 2023. 
 
You asked the Plan to pay for frame (V2025), progressive lenses (V2781), photochromatic lenses (V2744), 
high index lenses (V2782), deluxe lenses (V2702), and vision supplies/accessories (V2797). You say that you 
are appealing because of a denial letter you received regarding a service on your vision claim. The Plan denied 
your request. The Plan says the claim processed and paid for the eyewear up to your eyewear allowance of 
$200. The Plan also says this benefit has been exhausted. The Plan also says that the vision supplies/accessories 
(V2797) is denied as not a covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers a $200 allowance for non-Medicare-covered eyewear every year. Vision 
supplies/accessories (V2797) are excluded from this benefit. 
 
We looked at the file and the Plan's rules. The Plan rules also say that there is a $200 allowance for non-
Medicare-covered eyewear every year. Vision supplies/accessories (V2797) are excluded in this benefit. Based 
on this information, we decided that the Plan's rules for coverage of frame (V2025), progressive lenses 
(V2781), photochromatic lenses (V2744), high index lenses (V2782), deluxe lenses (V2702), and vision 
supplies/accessories (V2797) have not been met. Therefore, we decided that the Plan does not have to pay for 
frame (V2025), progressive lenses (V2781), photochromatic lenses (V2744), high index lenses (V2782), 
deluxe lenses (V2702), and vision supplies/accessories (V2797) provided on June 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the debridement of nails and the trimming 
of skin lesions provided by an out-of-network provider on March 22, 2023. 
 
You asked the Plan to waive the copayment for the debridement of nails and trimming of skin lesions. You say 
that you think that the copayment should be lower. 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 $50 
copayment for each out-of-network Medicare-covered podiatry visit.   
 
 You have been asked to pay a $50 copayment for the debridement of nails and trimming of skin lesions. These 
items/services fall within the podiatry 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 the debridement of nails and trimming of skin lesions provided by an out-of-network provider 
on March 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve a power wheelchair. You say that you are requesting reconsideration for the 
services. The Plan denied your request. The Plan says the enrollee must receive their care from a network 
provider (for more information about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives 
from an out-of-network provider (a provider who is not part of the plans network) will not be 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 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 
a power wheelchair 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 pre-approve the additional in-home support service hours. 
 
You asked the Plan to pre-approve the additional in-home support service hours. You say that you need 
additional Papa Pals hours because you are in need of a Bereavement Support Group and are unable to drive to 
the groups. The Plan denied your request. The Plan says the benefit limit has been reached. 
 
Medicare generally does not cover in-home support services. However, the Plan offers an in-home support 
services benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers an in-home support services benefit in excess of Medicare coverage, certain limitations 
apply. The record shows that your benefit for additional Papa Pals hours was exhausted on July 24, 2023, with 
a total of 60.25 houses of in-home support services. Therefore, we decided that the Plan does not have to pre-
approve the additional in-home support service hours.