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

 
We decided that the Plan does not have to pay for a specialist visit and a skin biopsy provided on September 
15, 2022. 
 
You asked the Plan to pay for a specialist visit and a skin biopsy. You say that you were not aware that this 
provider was out-of-network. 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 specialist visit and a 
skin biopsy provided on September 15, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the home health care services provided from 
December 6, 2022, to January 3, 2023. 
 
You asked the Plan to waive the deductible for the home health care services. You say that you would like this 
service to 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. Your 
contract with the Plan says that there is a $500 deductible which applies to home health agency care. Your 
contract with the Plan also says that there is a 0% coinsurance once your deductible has been met for home 
health care. 
 
 You have been asked to pay $380 towards your deductible for the home health care. The item or service you 
asked the Plan to waive the deductible for falls within the home health agency care benefit category. The Plan 
has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies 
to home health agency care. This cost sharing is a contractual obligation that had not been met at the time the 
home health care services was received on December 6, 2022, to January 3, 2023. Therefore, we decided that 
the Plan does not have to waive the deductible for the home health care services provided from December 6, 
2022, to January 3, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on November 25, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
services were medically necessary. You also say that the enrollee wanted to go to a different emergency room 
but they did not respond to the request. The Plan denied your request. The Plan says these services are not a 
covered benefit. 
 
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 November 25, 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 provided on November 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on March 29, 2022, to April 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services on March 29, 2022, to April 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 09, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support 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 an office visit provided 
on December 09, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on October 04, 2022. 
 
You asked the Plan to pay for wound care supplies. You say that you say that the supplies received are a 
separately billable expense and therefore a separate authorization is not required. 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 wound care supplies 
provided on October 04, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the drug administration and drug injection 
provided on December 30, 2022. 
 
You asked the Plan to waive the cost share for the drug administration and drug injection. You say that you 
would like to appeal these charges. 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 $250 
copayment for in-network outpatient surgical services. Your contract with the Plan also clearly says that you 
must pay 20% coinsurance for in-network Medicare Part B drugs. 
 
You have been asked to pay a $250 copayment for the drug administration. This item/service falls within the 
outpatient surgery benefit category. Due to meeting your out-of-pocket maximum during the processing of this 
claim, you have also been asked to pay $1,408.75, which is less than the standard 20% coinsurance for the drug 
injection. This item/service falls within the Medicare Part B drugs benefit category. You have been asked to 
pay a total of $1,658.75 ($250 copayment + $1,408.75 = $1,658.75). 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 share for the drug administration and drug injection provided on December 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management services provided on January 19, 
2023. 
 
You asked the Plan to pay for chronic care management services. You say that you have no prior knowledge of 
who you would be seeing. 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 January 19, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a positron emission tomography (PET) 
scan provided on December 16, 2022. 
 
You asked the Plan to waive the copayment for a positron emission tomography (PET) scan. You say that you 
should not have to pay for the PET scan that was scheduled incorrectly and now have to repeat 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $125 copayment for a positron emission tomography (PET) scan. This 
item/service falls within the outpatient diagnostic test 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 positron emission tomography (PET) scan provided on December 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye exam provided on November 15, 2022. 
 
You asked the Plan to pay for a medical eye exam. You say that a call was made to the primary care provider to 
obtain a referral. 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 medical eye exam 
provided on November 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on February 17, 2023. 
 
You asked the Plan to pay for lab testing. 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 lab testing provided on 
February 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee is diagnosed with severe 
COPD. The medical records document her disease is worsening resulting in more shortness of breath. The 
device is medically necessary. The Plan denied your request. The Plan says the request for a home mechanical 
ventilator set in AC mode with very low tidal volumes that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has severe COPD with a 
recent hospitalization. There is no documentation of chronic CO2 retention. The Life2000 system is not a true 
ventilator, because it is not capable of providing full ventilatory support.  There is inadequate evidence of the 
safety and efficacy of this device in the treatment of COPD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the eye exam provided on December 13, 
2022. 
 
You asked the Plan to waive the deductible for the eye exam. You say that you have never had to pay for this 
service in the past. 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 $500 deductible which applies to in-network vision services. Your 
contract with the Plan also says that you must pay a $10 copayment after meeting the deductible for an in-
network eye exam. 
 
The item or service you asked the Plan to waive the deductible for falls within the vision services benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to in-network vision services. This cost sharing is a contractual obligation that had not 
been met at the time the eye exam was received on December 13, 2022. Therefore, we decided that the Plan 
does not have to waive the deductible for the eye exam provided on December 13, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
October 22, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you did not ask to be 
transferred by 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 $220 
copayment for in-network ground ambulance services. 
 
You have been asked to pay a $220 copayment for the ambulance services. This item/service falls within the 
in-network ground 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 the ambulance services provided on October 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance image (MRI) 
provided on October 25, 2022. 
 
You asked the Plan to waive the copayment for a magnetic resonance image (MRI). You say that the test was 
unnecessary and you disagree with the copayment applied. 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 $160 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $160 copayment for a magnetic resonance image (MRI). This item/service falls 
within the outpatient diagnostic test 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 
magnetic resonance image (MRI) provided on October 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on January 05, 2023. 
 
You asked the Plan to pay for ophthalmological services. You say that you say you have a previous condition 
of floaters/migraines and went to see a specialist to make sure the retina was not detached. 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 ophthalmological 
services provided on January 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on January 09, 2023. 
 
You asked the Plan to pay for nursing facility care. You say that this is supported in the 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 nursing facility care 
provided on January 09, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the lymph node surgery and diagnostic 
mammogram provided on January 3, 2023. 
 
You asked the Plan to waive the cost share for the lymph node surgery and diagnostic mammogram. You say 
that this should be considered a follow-up to a previous procedure. 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 $525 in-network deductible which applies to in-network outpatient 
surgery. Your contract with the Plan also says that you must pay 10% coinsurance after meeting the deductible for in-network outpatient surgery. Your contract with the Plan also says that you must pay a $10 copayment for 
in-network mammograms. 
 
The item or service you have asked the Plan to waive the deductible for falls within the outpatient surgery 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $525 
in-network deductible which applies to in-network outpatient surgery. This cost sharing is a contractual 
obligation that had not been met at the time the lymph node surgery and diagnostic mammogram was received 
on January 3, 2023.  
 
You have also been asked to pay 10% coinsurance of the allowed amount for the lymph node surgery. This 
item/service falls within the outpatient surgery benefit category. You have also been asked to pay a $10 
copayment for the diagnostic mammogram. This item/service falls within the outpatient diagnostic tests and 
therapeutic 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 cost share for the lymph node 
surgery and diagnostic mammogram provided on January 3, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on November 
28, 2022. 
 
You asked the Plan to waive the copayment for the arthrocentesis. You say that you were told by the provider 
that the Plan would pay 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 a $195 
copayment for outpatient surgery at an outpatient hospital facility. 
 
You have been asked to pay a $195 copayment for the arthrocentesis. This item/service falls within the 
outpatient surgery at an outpatient hospital facility 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 arthrocentesis provided on November 28, 2022.