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

 
We decided that the Plan does not have to waive the copayment for the abdominal ultrasound provided on May 
23, 2023. 
 
You asked the Plan to waive the copayment for the abdominal ultrasound. You say that you do not understand 
why this was not 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 $150 
copayment for in-network outpatient diagnostic tests, including ultrasounds. 
 
You have been asked to pay a $150 copayment for the abdominal ultrasound. This item/service falls within the 
in-network outpatient diagnostic tests, including ultrasounds 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 abdominal ultrasound provided on May 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rest home visit for the evaluation and management 
provided on August 10, 2022. 
 
You asked the Plan to pay for a rest home visit for the evaluation and management. 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 a rest home visit for the 
evaluation and management provided on August 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
April 25, 2023, to April 29, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that your stay was extended 
due to waiting on a decision from the Plan. 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 $395 
copayment per day for days 1-5 of each in-network inpatient hospital stay. Your contract with the Plan also 
clearly says that you then pay a $0 copayment per day for days 6-90 of each in-network inpatient hospital stay. 
 
You have been asked to pay a $395 copayment per day for days 1-4 of the inpatient hospital stay. This 
item/service falls within the inpatient hospital care benefit category. You have not been asked to pay after day 
four or for the day you were discharged. You have been asked to pay a total of $1,580 ($395 copayment per 
day x 4 days = $1,580). 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 from April 25, 2023, to April 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 16, 2023. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided 
on May 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 23, 2023. 
 
You asked the Plan to pay for an office visit. 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 provided 
on May 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 23, 2023. 
 
You asked the Plan to pay for the office visit. 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 office visit provided 
on March 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the lab services provided by an in-network 
provider on June 6, 2023.  
 
You asked the Plan to waive the deductible for the lab services. You say that you did not think that you had a 
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 $233 deductible which applies to in and out-of-network lab services.   
 
You have been asked to pay a $142.10 deductible for the lab services. The items or services you asked the Plan 
to waive the deductible for fall within the outpatient diagnostic tests and therapeutic services and supplies 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $233 
deductible which applies to outpatient diagnostic tests and therapeutic services and supplies. This cost sharing 
is a contractual obligation that had not been met at the time the lab services were provided on June 6, 2023. 
Therefore, we decided that the Plan does not have to waive the deductible for the lab services provided by an 
in-network provider on June 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cystourethroscopy procedure provided on May 11, 2023. 
 
You asked the Plan to pay for the cystourethroscopy procedure. 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 cystourethroscopy 
procedure provided on May 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation and the laboratory services provided on May 
25, 2023, to May 26, 2023. 
 
You asked the Plan to pay for a consultation and the laboratory services. 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 consultation and the 
laboratory services provided on May 25, 2023, to May 26, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance transportation provided on 
April 10, 2023. 
 
You asked the Plan to waive the copayment for an ambulance transportation. You say that you were not 
transported on this date of 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 $270 
copayment for ambulance services. 
 
You have been asked to pay a $270 copayment for an ambulance transportation. 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 an 
ambulance transportation provided on April 10, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the inpatient hospital stay provided on 
May 11, 2023, to May 13, 2023. 
 
You asked the Plan to waive the coinsurance for the inpatient hospital stay. You say that you do not understand 
why the Plan is charging your benefits for this when you never paid anything before. 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 5% 
coinsurance for in-network inpatient hospital care. 
 
You have been asked to pay 5% coinsurance for the inpatient hospital stay. This item/service falls within the 
in-network 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. The total you owe is $825.99 ($16,519.80 allowed amount x 5% coinsurance = 
$825.99). Therefore, we decided that the Plan does not have to waive the coinsurance for the inpatient hospital 
stay provided on May 11, 2023, to May 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on May 5, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the nursing facility care. 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 nursing facility care provided on May 5, 2023, 
by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0657). 
 
You asked the Plan to pre-approve the pneumatic compression device. You say that this device is medically 
necessary. The Plan denied your request. The Plan says coverage rules have not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652, E0657).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit evaluation provided on April 19, 2023. 
 
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 April 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dialysis procedures, and related services provided from 
March 1, 2023, to March 31, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the dialysis procedures, and related services. You say that these services were 
medically necessary. 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 items/services at issue in this appeal. The Plan did not pre-approve the 
items/services 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 dialysis procedures, and related services 
provided from March 1, 2023, to March 31, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift unit (E1399). 
 
You asked the Plan to pre-approve the seat lift unit. You say that this item is medically necessary. The Plan 
denied your request. The Plan says the plan has already approved items that serve the same purpose as the 
requested lift. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a manual lift and transport chair. The manual lift and transport chair serve the 
same purpose as the seat lift unit. Therefore, we decided that the Plan does not have to pre-approve a seat lift 
unit (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote device evaluation provided on May 12, 2023, by 
an OON provider.  
 
You asked the Plan to pay for the remote device evaluation. 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 
non-Medicare covered dental services covered by the Plan. 
 
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 remote device evaluation provided on May 12, 
2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 10, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. 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 subsequent nursing 
facility care provided on May 10, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the breast cancer screening services 
provided on February 15, 2023. 
 
You asked the Plan to waive the coinsurance for the breast cancer screening services. You say that you were 
not aware this provider is out-of-network. 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 50% 
coinsurance for out-of-network breast cancer screening.  
You have been asked to pay 50% coinsurance for the breast cancer screening services. This item/service falls 
within the out-of-network breast cancer screening 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 breast cancer screening services provided on February 15, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health visit provided on May 10, 2023. 
 
You asked the Plan to pay for the home health visit. You say that a referral is not required, and that a referral 
had been received 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 the home health visit 
provided on May 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 14, 2023. 
 
You asked the Plan to pay for the laboratory services. 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 laboratory services 
provided on March 14, 2023.