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

 
We decided that the Plan does not have to pay for the laboratory services provided on February 07, 2023. 
 
You asked the Plan to pay for 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 the laboratory services 
provided on February 07, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for oxygen equipment on January 30, 2023.  
 
You asked the Plan to waive the coinsurance for oxygen equipment. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment provider. Covered items include, but are not limited to wheelchairs, 
crutches, powered mattress systems, diabetic supplies, hospital beds ordered by a provider for use in the home, 
IV infusion pumps, speech generating devices, oxygen equipment, nebulizers, continuous glucose monitors, 
and walkers. The provider billed in the amount of $54.05 and the allowed amount is $36.53 for the service. 
$36.53 x 20% = $7.31. Therefore, results in the total cost sharing amount of $7.31. 
 You have been asked to pay a 20% coinsurance for oxygen equipment. This item/service falls within the 
durable medical equipment (DME) and related supplies benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the coinsurance for oxygen equipment on January 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 6, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that there is no contractual 
agreement that indicates that these tests should be included in the dialysis rate. The Plan denied your request. 
The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 15, 2023. 
 
You asked the Plan to pay for lab services. 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 lab services provided on 
January 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit for evaluation provided on March 06, 2023. 
 
You asked the Plan to pay for home visit for evaluation. You say that you say that the assisted living facility 
was responsible for authorization. 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 home visit for 
evaluation provided on March 06, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for to pay for his service, you should not  
 
You asked the Plan to waive the deductible for . You say that this was part of your annual and it should not 
have a had a 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. Your 
contract with the Plan says that there is a $300 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies. You are being asked to pay $197.82 towards your $300 deductible. 
 
The item or service you asked the Plan to waive the deductible for falls 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 $300 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 
was received on January 16, 2023. Therefore, we decided that the Plan does not have to waive the deductible 
for to pay for his service, you should not
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on April 18, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services rendered 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 April 18, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an office or other outpatient visit, a therapeutic, prophylactic, or 
diagnostic injection, Anastrozole, oral, 1 mg, an injection, testosterone cypionate, 1 mg and an injection, 
chorionic gonadotropin provided from January 15, 2022, to October 15, 2022. 
 
You asked the Plan to pay for the office or other outpatient visit, a therapeutic, prophylactic, or diagnostic 
injection, Anastrozole, oral, 1 mg, an injection, testosterone cypionate, 1 mg and an injection, chorionic 
gonadotropin. You say that the service in question, namely office visits, have not been reimbursed or 
duplicated as of this writing and stand as valid services in need of reimbursement. The Plan denied your 
request. The Plan says that claim not being filed until February 6, 2023 without good cause and the service is 
included in another service provided at the same time by the same provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided proof that the claims were filed untimely, 
Also, the Plan has not provided proof that the services were included in another service. Therefore, we decided 
that the Plan has to pay for an office or other outpatient visit, a therapeutic, prophylactic, or diagnostic 
injection, Anastrozole, oral, 1 mg, an injection, testosterone cypionate, 1 mg and an injection, chorionic 
gonadotropin provided from January 15, 2022, to October 15, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on March 03, 2023. 
 
You asked the Plan to pay for a nursing facility visit. You say that this was medically necessary and 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 nursing facility visit 
provided on March 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an in-network specialist visit provided on 
February 8, 2023. 
 
You asked the Plan to waive the deductible for an in-network specialist visit. You say that this provider did not 
know what they were doing. You left feeling more confused, you should not have to 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. Your 
contract with the Plan says that there is a $625 deductible which applies to Physician/Practitioner services, 
including doctor's office visits. You are being asked to pay a $205.77 towards your deductible. 
 
The item or service you asked the Plan to waive the deductible for falls within the Physician/Practitioner 
services, including doctor's office visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $625 deductible which applies to Physician/Practitioner services, 
including doctor's office visits.  This cost sharing is a contractual obligation that had not been met at the time an in-network specialist visit was 
received on February 8, 2023. Therefore, we decided that the Plan does not have to waive the deductible for an 
in-network specialist visit provided on February 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the radiation therapy services provided on 
September 26, 2022, and September 28, 2022. 
 
You asked the Plan to waive the coinsurance for the radiation therapy services. You say that you did not 
receive radiation therapy on these dates. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay 20% coinsurance for outpatient diagnostic tests and therapeutic services and supplies.  
 
 The enrollee has been asked to pay 20% coinsurance for each covered therapeutic radiology service. These 
items/services fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category.  
 
Date of Service Item Allowed Amount 20% Coinsurance 
  September 26, 2022, to 
September 28, 2022 
Radiation therapy $1,160.32 $232.06 
September 28, 2022 Radiation therapy $1,833.24 $366.65 
September 28, 2022 Radiation therapy $250.11 $50.02 
 
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This 
cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we 
decided that the Plan does not have to waive the coinsurance for the radiation therapy services provided on 
September 26, 2022, and September 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery on September 22, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for each Medicare-covered outpatient hospital facility visit. Covered services include but are not 
limited to the following and cost sharing may apply services in an emergency department or outpatient clinic, 
such as observation services or outpatient surgery. The provider billed in the amount of $455 and the allowed 
amount is $270.38 for the service. This is less than the copayment amount. Therefore, results in the total cost 
sharing amount of $270.38. 
 You have been asked to pay a $270.38 copayment, which is less than the copayment for outpatient surgery. 
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. Therefore, we decided that the Plan does not have 
to waive the copayment for outpatient surgery on September 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the specialist office visit and the faricimab 
injections provided on February 15, 2023. 
 
You asked the Plan to waive the cost share for the specialist office visit and the injections. You say that you 
cannot afford the cost share. 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 services received from an in-network level 1 specialist physician. Your contract with the Plan 
also clearly says that you must pay 20% coinsurance for chemotherapy drugs, infusion drugs, and all other 
drugs covered under Medicare Part B. 
 
You have been asked to pay a $35 copayment for the specialist office. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. 
 
You have also been asked to pay $444.81, which is 20% coinsurance of the allowed amount for each injection 
($2,224.04 allowed amount x 20% = $444.81). You have been asked to pay a total of $889.62 for the injections 
($444.81 coinsurance x 2 injections = $889.62). These items/services fall within the Medicare Part B 
prescription 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 cost share for the specialist office 
visit and the faricimab injections provided on February 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481 and 87653 billed for date of service 
November 18, 2022. 
 You asked the Plan to pay for procedure codes 87481 and 87653. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for codes 87481 and 87653 is bundled into 
payment for code 87801. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
87481 and 87653 are column II codes to column I code 87801. This claim has not been billed with an 
appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 87481 and 87653 billed for 
date of service November 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit for evaluation provided on March 06, 2023. 
 
You asked the Plan to pay for home visit for evaluation. You say that you say that the physicians renders 
medical care as requested by the facility. 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 home visit for 
evaluation provided on March 06, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
February 11, 2023. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that it is not your fault you 
had to go to the emergency room. 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 the 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 the emergency room visit 
provided on February 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 23, 2023. 
 
You asked the Plan to pay for the office visit. You say that the office visit was for a consultation that was 
necessary to diagnosis and create a treatment plan to address your back pain. The Plan denied your request. The 
Plan says an office visit is not a covered chiropractic benefit.  
 
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 records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office visit provided on January 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on March 13, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that your therapist is listed as in-network with the 
Plan. The Plan denied your request. The Plan says a Mental Health Counselor is on the list of individuals who 
are not eligible to enroll in Medicare.  
 
The Plan must follow Medicare rules. Medicare rules say that a Mental Health Counselor is not eligible to 
participate in the Medicare program.  
 
We looked at the file and Medicare rules. The provider at issue in this case is a Mental Health Counselor. 
Medicare says that a Mental Health Counselor is not eligible to participate in the Medicare program.  
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on March 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the nuclear medicine imaging study 
provided on April 17, 2023. 
 
You asked the Plan to waive the copayment for the nuclear medicine imaging study. You say that your spouse 
had the same procedure without any 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 $230 
copayment for in-network outpatient diagnostic tests, including nuclear medicine. 
 
You have been asked to pay a $230 copayment for the nuclear medicine imaging study. This item/service falls 
within the in-network outpatient diagnostic tests, including nuclear medicine 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 nuclear medicine imaging study provided on April 17, 2023.