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

 
We decided that the Plan does not have to pay for the acupuncture visits provided on May 19, 2023, to July 21, 
2023. 
 
You asked the Plan to pay for the acupuncture visits. You say that you should not have to pay for your visits 
because you called your insurance and they approved the visits. 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 the acupuncture visits 
provided on May 19, 2023, to July 21, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network emergency room (ER) visit 
provided on May 21, 2023. 
 
You asked the Plan to waive the copayment for an in-network emergency room (ER) visit. You say that you 
feel you were mislead in going to the ER, and feel you should not need to pay as they could not help. 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 $110 
copayment for emergency care. 
 
You have been asked to pay a $110 copayment for an in-network emergency room (ER) visit. This item/service 
falls 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. However, since the allowed amount is less than the standard copayment, you 
only owe $72.92. Therefore, we decided that the Plan does not have to waive the copayment for an in-network 
emergency room (ER) visit provided on May 21, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each intravenous infusion provided on July 
13, 2023, to July 21, 2023. 
 
You asked the Plan to waive the copayment for each intravenous infusion. 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 $295 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical. 
 
You have been asked to pay a $295 copayment for each intravenous infusion. This item/service falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical 
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. 
However, since the allowed amount is less than the standard copayment, the total you owe is $424.32 ($212.16 
copayment x 2 visits = $424.32). Therefore, we decided that the Plan does not have to waive the copayment for 
each intravenous infusion provided on July 13, 2023, to July 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the abscess drainage procedure provided on 
June 8, 2023. 
 
You asked the Plan to waive the copayment for the abscess drainage procedure. You say that you had met your 
MOOP amount prior to this 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for services from an out-of-network specialist.  
 
The record shows you had not met your MOOP prior to this service. You have been asked to pay a $40 
copayment for the abscess drainage procedure. 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 the abscess drainage procedure provided on June 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the medical supplies provided on July 19, 
2023. 
 
You asked the Plan to waive the cost sharing for the medical supplies. You say that you returned the supplies to 
the provider. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan 
contract says that enrollees must pay a 20% coinsurance for durable medical equipment (DME) and related 
supplies. 
 
 
 You have been asked to pay a $53.25 coinsurance for the medical supplies ($266.26 allowed amount x .20 = 
$53.25). The medical supplies fall 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. Therefore, we 
decided that the Plan does not have to waive the cost sharing for the medical supplies provided on July 19, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on March 02, 2023. 
 
You asked the Plan to pay for the home visit. 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 the home visit provided 
on March 02, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmological services and the office visit provided 
on July 31, 2023. 
 
You asked the Plan to pay for the ophthalmological services and the office visit. 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 the ophthalmological 
services and the office visit provided on July 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on July 7, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on July 7, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit and radiology provided on 
June 28, 2023. 
 
You asked the Plan to pay for a hospital outpatient clinic visit and radiology. You say that the services were 
medically necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a hospital outpatient 
clinic visit and radiology provided on June 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 17, 2023. 
 
You asked the Plan to pay for lab services. You say that you received a valid referral for these services. 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 lab services provided on 
January 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telephone evaluations provided on April 06, 2023, to 
May 31, 2023. 
 
You asked the Plan to pay for the telephone evaluations. 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 the telephone 
evaluations provided on April 06, 2023, to May 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on July 21, 2023. 
 
You asked the Plan to pay for the office visit. 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 the office visit provided 
on July 21, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for in-network emergency room (ER) visits 
provided on August 02, 2023, to August 12, 2023. 
 
You asked the Plan to waive the copayment for in-network emergency room (ER) visits. You say that you kept 
having to go to the ER because of a procedure you had. The hospital should waive these. 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 $110 
copayment for emergency care. 
 
You have been asked to pay a $110 copayment for in-network emergency room (ER) visits. This item/service 
falls 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. The total you owe is $220 ($110 copayment x 2 visits = $220). Therefore, we 
decided that the Plan does not have to waive the copayment for in-network emergency room (ER) visits 
provided on August 02, 2023, to August 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 13, 2023. 
 
You asked the Plan to pay for the office visit. You say that with the new state balance billing protection law 
you would like you claim reprocessed. 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 the office visit provided 
on February 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for dates of service July 16, 
2023, to August 12, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
were ordered by an in-network provider. The Plan denied your request. The Plan says the billed code is invalid 
for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for dates of service July 16, 2023, to August 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment provided on June 28, 
2023. 
 
You asked the Plan to pay for the chiropractic manipulative treatment. You say that you are appealing the claim 
payment denial. 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 the chiropractic 
manipulative treatment provided on June 28, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the hip x-rays provided by an in-network 
provider on June 21, 2023. 
 
You asked the Plan to waive the cost sharing for the x-rays. You say that you do not agree with the cost 
sharing. 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 $800 deductible, and that you must pay a 10% coinsurance of the 
approved amount and the annual deductible applies for in and out-of-network diagnostic tests, including x-rays. 
 
 
 
 
 You have been asked to pay a $1.06 coinsurance for the x-rays ($10.60 allowed amount x .10 = $1.06). You 
have also been asked to pay a $9.54 deductible for the x-rays. The items or services you asked the Plan to 
waive the cost sharing for fall within the diagnostic tests benefit category. The Plan has followed Medicare 
rules by clearly disclosing in the contract that there is a $800 deductible which applies to diagnostic tests. This 
cost sharing is a contractual obligation that had not been met at the time the x-rays were received on June 21, 
2023. Therefore, we decided that the Plan does not have to waive the cost sharing for the hip x-rays provided 
by an in-network provider on June 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on July 05, 2023. 
 
You asked the Plan to pay for the laboratory service. 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 the laboratory service 
provided on July 05, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on June 30, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you are appealing the denial with supporting 
documentation. 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 the laboratory service 
provided on June 30, 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 August 24, 
2023. 
 
You asked the Plan to pay for the subsequent nursing facility care. 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 the subsequent nursing 
facility care provided on August 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on April 23, 
2023. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you are unable to 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 $60 
copayment for each in-network Medicare-covered urgent care facility visit. 
 
You have been asked to pay a $60 copayment for an urgent care visit. This item/service falls within the each in-
network Medicare-covered urgent care facility 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 urgent care visit provided on April 23, 2023.