Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on April 1, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
in an accident, an ambulance was called to the site, and you were examined but not transported anywhere. You 
also say that you were told the Plan would pay half of the total bill and you would be responsible for the 
remainder. The Plan denied your request. The Plan says since there was no transport, ambulance charges are 
not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 1, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on April 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 08, 2023. 
 
You asked the Plan to pay for an office visit. You say that this service was 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 an office visit provided 
on March 08, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on March 13, 
2023. 
 
You asked the Plan to waive the copayment for laboratory 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 $45 
copayment for outpatient hospital services/lab services. 
 
You have been asked to pay a $45 copayment for laboratory services. This item/service falls within the 
outpatient hospital services/lab 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 laboratory services provided on March 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hip injection provided on March 16, 
2023. 
 
You asked the Plan to waive the copayment for the hip injection. You say that you were told that this injection 
would be fully covered. 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 for outpatient hospital services. 
 
You have been asked to pay a $350 copayment for the hip injection. This item/service falls within the 
outpatient hospital 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. However, since the allowed amount is less than the standard copayment, you only owe 
$320.57. Therefore, we decided that the Plan does not have to waive the copayment for the hip injection 
provided on March 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on December 28, 2022. 
 
You asked the Plan to pay for outpatient services. You say that you are requesting reconsideration for the 
services 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 outpatient services 
provided on December 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for segmental gradient pressure pneumatic appliance provided 
on October 26, 2022. 
 
You asked the Plan to pay for segmental gradient pressure pneumatic appliance. 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 segmental gradient 
pressure pneumatic appliance provided on October 26, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each ambulance service provided on March 
21, 2023, to March 23, 2023. 
 
You asked the Plan to waive the copayment for each ambulance service. You say that the ambulance company 
said the Plan had not yet responded to these claims. 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 each ambulance service. 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. However, since the allowed amount for each service is less than the standard copayment, you are 
only being asked to pay the allowed amount for each date of service. Therefore, we decided that the Plan does 
not have to waive the copayment for each ambulance service provided on March 21, 2023, to March 23, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic injection and office visits provided on 
February 01, 2023, to February 22, 2023. 
 
You asked the Plan to pay for the therapeutic injection and office visits. 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 therapeutic injection 
and office visits provided on February 01, 2023, to February 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on March 17, 
2023. 
 
You asked the Plan to pay for an office visit and related 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 an office visit and 
related services provided on March 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the drug injections provided on January 
24, 2023. 
 
You asked the Plan to waive the coinsurance for the drug injections. You say that you were not made aware of 
the cost sharing information for 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 20% 
coinsurance for Medicare Part B drugs. 
 
You have been asked to pay 20% coinsurance for the drug injections. This item/service falls within the 
Medicare Part B drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the drug 
injections provided on January 24, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a emergency room visit provided on 
February 22, 2023. 
 
You asked the Plan to waive the copayment for a emergency room visit. 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 $95 
copayment for emergency care. 
 
You have been asked to pay a $95 copayment for a emergency room 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. Therefore, we decided that the Plan does not have to waive the copayment for a emergency room visit 
provided on February 22, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on January 4, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the Plan requires utilization of network providers when possible and 
available and requires authorization for certain services. No medical necessity for an out-of-network provider 
such as an urgent or an emergent situation that has been documented.   
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for psychotherapy provided on January 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam provided on November 14, 
2022. 
 
You asked the Plan to waive the copayment for the eye exam. You say that this should be included with a $0 
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 $45 
copayment for vision care. 
 
You have been asked to pay a $45 copayment for the eye exam. This item/service falls within the vision 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 eye exam provided on 
November 14, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on August 16, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the laboratory services by a contract provider. The file does not show that the Plan 
provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the Plan. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on August 16, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 20, 2021. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says this claim 
was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until February 28, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on September 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 03, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration with supporting 
medical records. 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 an office visit provided 
on April 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 5, 2023, by an OON 
provider.  
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says this 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 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 an office visit provided on January 5, 2023, by an 
OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on January 25, 
2023. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this information, we decided that Medicare rules for coverage of the DecisionDx-SCC test have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on 
January 25, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a spinal injection provided on January 16, 
2023. 
 
You asked the Plan to waive the deductible for an injection. You say that you disagree with the deductible. 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 $750 deductible which applies to outpatient surgery, including 
services provided at ambulatory surgical centers.  
 
 
 
 You have been asked to pay $415.05 towards your deductible for the injection. The item or service you asked 
the Plan to waive the deductible for falls within the outpatient surgery, including services provided at 
ambulatory surgical centers benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $750 deductible which applies to outpatient surgery, including services provided at 
ambulatory surgical centers. This cost sharing is a contractual obligation that had not been met at the time an 
injection was received on January 16, 2023. Therefore, we decided that the Plan does not have to waive the 
deductible for a spinal injection provided on January 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit evaluation provided on June 14, 2022. 
 
You asked the Plan to pay for a home visit evaluation. 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 home visit evaluation 
provided on June 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-rays provided on January 31, 2023, by an out-of-network 
(OON) provider.  
 
You asked the Plan to pay for x-rays. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says if the enrollee receives care from an out-of-network provider (a provider who is not part 
of the plans network), such services will not be covered unless the enrollee obtains a prior authorization.  
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 x-rays provided on January 31, 2023, by an out-of-
network (OON) provider.