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

 
We decided that the Plan does not have to pay for the office visit and the urinalysis provided on March 20, 
2023. 
 
You asked the Plan to pay for the office visit and the urinalysis. 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 and the 
urinalysis provided on March 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection of a drug provided on February 28, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the injection. You say that this is supported in the records. 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 injection of a drug provided on February 28, 2023, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on June 14, 2023. 
 
You asked the Plan to pay for lab testing. 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 lab testing provided on 
June 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on May 
23, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you had to cancel the 
surgery for this date as you did not have anybody to accompany you. 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 in-network specialist physician/practitioner services. 
 
You have been asked to pay a $40 copayment for the specialist office visit. This item/service falls within the 
in-network specialist physician/practitioner 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 record shows this claim was approved and you are 
responsible for the cost share amount. Therefore, we decided that the Plan does not have to waive the 
copayment for the specialist office visit provided on May 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatment (G2067) and the take home 
supply of methadone (G2078) provided on April 10, 2023, by an OON provider.  
 
You asked the Plan to pay for the medication assisted treatment and the take home supply of methadone. You 
say that you are requesting reconsideration of the denied claim. 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 medication assisted treatment (G2067) and the 
take home supply of methadone (G2078) provided on April 10, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic care provided on May 16, 2023, to June 02, 
2023. 
 
You asked the Plan to pay for the chiropractic 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 chiropractic care 
provided on May 16, 2023, to June 02, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cardiovascular stress test provided on May 
19, 2023. 
 
You asked the Plan to waive the copayment for cardiovascular stress test. You say that you say that you do not 
agree with the copayment assessed with the office visit. 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 cardiovascular stress test. 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 cardiovascular stress test provided on May 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on May 10, 2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you say that you do not agree with 
the copayment assessed with the office visit. 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 office 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 office visit provided on May 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on May 28, 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 May 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement provided on May 19, 2023. 
 
You asked the Plan to pay for the debridement. 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 debridement 
provided on May 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor (99213), 
chiropractic manipulative treatment (98940 x 2), electrical stimulation (G0283 x 2) and mechanical traction 
(97012 x 2) provided from May 11, 2023, to May 24, 2023. 
 You asked the Plan to pay for the chiropractic services. You say that these services relieve your low back pain 
and avoid the need for injections or an operation. The Plan denied your request. The Plan says these 
chiropractic services are excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. 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 copayment for each covered chiropractic visit. 
 
The records show that the office visit, electrical stimulation and mechanical traction at issue is not manual 
manipulation of the spine. You have been asked to pay a $20 copayment for each chiropractic manipulative 
treatment. This item/service falls within the Chiropractic Service 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 pay for the office visit provided by a chiropractor (99213), chiropractic manipulative treatment (98940 x 2), 
electrical stimulation (G0283 x 2) and mechanical traction (97012 x 2) provided from May 11, 2023, to May 
24, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on March 08, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with 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 $275 
copayment for ambulance services. 
 
You have been asked to pay a $275 copayment for ambulance services. This item/service falls within the 
ambulance 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 ambulance services 
provided on March 08, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test provided on April 19, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the drug test. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 drug test provided on April 19, 2023, by an 
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management services provided on April 30, 
2023. 
 
You asked the Plan to pay for chronic care management services. You say that the services should be covered. 
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 chronic care 
management services provided on April 30, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the computed tomography (CT) scan 
provided on May 05, 2023. 
 
You asked the Plan to waive the coinsurance for the computed tomography (CT) scan. You say that the 
incorrect test was ordered, and you will not pay for it. 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 outpatient diagnostic radiology.  
You have been asked to pay 20% coinsurance for the computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic radiology 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 $51.49 ($257.47 allowed amount x 20% coinsurance = 
$51.49). Therefore, we decided that the Plan does not have to waive the coinsurance for the computed 
tomography (CT) scan provided on May 05, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on April 26, 2023. 
 
You asked the Plan to pay for the drug testing. 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 the drug testing 
provided on April 26, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on March 09, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you feel that you shouldnt 
have to pay for the ambulance. 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 $215 
copayment for ambulance services. 
 
You have been asked to pay a $215 copayment for ambulance services. This item/service falls within the 
ambulance 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 ambulance services 
provided on March 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on April 27, 2023. 
 
You asked the Plan to pay for the wound care supplies. 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 wound care supplies 
provided on April 27, 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 
in-network provider from July 19, 2023, to July 22, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. 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 (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment per day, days 1-5, for each in-network Medicare-covered hospital admission/stay. 
 
 You have been asked to pay a $1050 copayment for the inpatient hospital stay ($350 copayment x 3 days = 
$1050). 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 in-network provider from July 19, 2023, 
to July 22, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the chemotherapy services provided on 
July 14, 2020. 
 
You asked the Plan to waive the coinsurance for the chemotherapy services. You say that you disagree with the 
coinsurance. 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 in-network Medicare Part B covered chemotherapy drugs.  
 
You have been asked to pay 20% coinsurance for the chemotherapy services. These items/services fall within 
the Medicare Part B prescription drugs benefit category. 
 
Date of Service Item Allowed Amount 20% coinsurance 
July 14, 2023 Chemotherapy administration $28.22 $5.64 
July 14, 2023 Rituximab injection $460.10 $92.02 
July 14, 2023 Chemotherapy administration $54.99 $11.00 
July 14, 2023 Chemotherapy infusion $130.02 $26.00 
July 14, 2023 Palonosetron injection $49.40 $9.88 
July 14, 2023 Bendeka injection $3,565.35 $713.07 
July 14, 2023 Rituximab injection $8,741.90 $1,748.38 
July 14, 2023 Rituximab injection $460.10 $92.02 
July 14, 2023 Dexamethasone injection $1.30 $0.26 
July 14, 2023 Diphenhydramine injection $1.96 $0.39 
 
 This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for the chemotherapy services provided on July 14, 2020.