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

 
We decided that the Plan does not have to pay for an office visit provided on May 30, 2023. 
 
You asked the Plan to pay for an office 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 an office visit provided 
on May 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on May 4, 
2023, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that the services rendered were medically 
necessary. The Plan denied your request. The Plan says enrollees generally must receive their care from a 
network provider.  
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The service at issue in this appeal was not provided in an emergency or urgent care situation. The services were 
not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have 
to pay for the subsequent nursing facility care provided on May 4, 2023, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for in-network ambulance rides provided on 
June 04, 2023, to June 20, 2023. 
 
You asked the Plan to waive the copayment for in-network ambulance rides. You say that you have an 
assistance program that should be covering this. You should not owe anything. 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 $200 
copayment for ambulance services. 
 
You have been asked to pay a $200 copayment for in-network ambulance rides. 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. The total you owe is $400 ($200 copayment x 2 rides = $400). Therefore, we decided that 
the Plan does not have to waive the copayment for in-network ambulance rides provided on June 04, 2023, to 
June 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 27, 2023. 
 
You asked the Plan to pay for subsequent 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 subsequent nursing 
facility care provided on June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implantable device and the injections provided on May 
09, 2023. 
 
You asked the Plan to pay for the implantable device and the injections. You say that you are appealing the 
denial with supporting documentation. 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 implantable device 
and the injections provided on May 09, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the speech therapy service on April 12, 
2023.  
 
You asked the Plan to waive the deductible for the speech therapy service. You say that the deductible was met 
at the time 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. Your 
contract with the Plan says that there is a $750 deductible which applies to outpatient rehabilitation services.  
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient rehabilitation 
services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $750 deductible which applies to outpatient rehabilitation services. This cost sharing is a contractual 
obligation that had not been met at the time the speech therapy service was received on April 12, 2023. 
Therefore, we decided that the Plan does not have to waive the deductible for the speech therapy service on 
April 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dermatology office visit provided on May 10, 2023. 
 
You asked the Plan to pay for a dermatology office 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 dermatology office 
visit provided on May 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on June 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the dental services were received from an out-of-network provider 
and are not covered by your supplemental benefits.  
 
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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided on June 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic care to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve chiropractic care. You say that you are requesting reconsideration for the 
service provided. The Plan denied your request. The Plan says the enrollee must receive their care from a 
network provider (for more information about this, see Section 2 of Chapter 3). In most cases, care the enrollee 
receives from an out-of-network provider (a provider who is not part of the plans network) will not be 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers.  
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
chiropractic care to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mental health visit provided on May 05, 2023. 
 
You asked the Plan to pay for a mental health visit. You say that this was medically necessary, please approve 
this 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 mental health visit 
provided on May 05, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee x-ray provided on July 5, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the knee x-ray. You say that you are appealing the denial with supporting 
documentation. The Plan denied your request. The Plan says the service was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the knee x-ray provided on July 5, 2023, by an 
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment and acupuncture 
provided on June 14, 2023, by an OON provider.  
 
You asked the Plan to pay for the chiropractic manipulative treatment and acupuncture. You say that you are 
requesting reconsideration of the denied claim. The Plan denied your request. The Plan says the service was not 
authorized. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the chiropractic manipulative treatment and 
acupuncture provided on June 14, 2023, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for flow cytometry interpretation provided on February 22, 
2023. 
 
You asked the Plan to pay for flow cytometry interpretation. 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 flow cytometry 
interpretation provided on February 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each specialist office visit provided on 
March 15, 2023, to April 18, 2023. 
 
You asked the Plan to waive the copayment for each specialist office visit. You say that you should not have 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for each specialist office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total amount you owe is $80 ($40 copayment 
x 2 visits = $80). Therefore, we decided that the Plan does not have to waive the copayment for each specialist 
office visit provided on March 15, 2023, to April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a preventive medicine examination 
provided on February 28, 2023. 
 
You asked the Plan to waive the coinsurance for a preventive medicine examination. You say that there should 
be no 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 40% 
coinsurance for out-of-network annual wellness visits. 
 
You have been asked to pay 40% coinsurance for a preventive medicine examination. This item/service falls 
within the out-of-network annual wellness visits benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total you owe is $54.81 ($137.03 allowed amount x 40% = 
$54.81). Therefore, we decided that the Plan does not have to waive the coinsurance for a preventive medicine 
examination provided on February 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deducible for outpatient surgery on May 23, 2023.  
 
You asked the Plan to waive the deducible 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. Your 
contract with the Plan says that there is a $750 deductible which applies to outpatient surgery and other medical 
services provided at hospital outpatient facilities and ambulatory surgical centers.  
 
The item or service you asked the Plan to waive the deducible for falls within the outpatient surgery and other 
medical services provided at hospital outpatient facilities and 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 and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers. This cost sharing is a contractual obligation that had not been met at the time 
outpatient surgery was received on May 23, 2023. Therefore, we decided that the Plan does not have to waive 
the deducible for outpatient surgery on May 23, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychotherapy visit provided on April 27, 2023. 
 
You asked the Plan to pay for a psychotherapy visit. You say that this provider is in-network and this should be 
covered. It is 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 a psychotherapy visit 
provided on April 27, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve atezolizumab. 
 
You asked the Plan to pre-approve the drug. You say that the enrollee has suffered with chemotherapy induced 
nausea., and this mediation is proven to be effective for the enrollee. The Plan denied your request. The Plan 
says that the requested drug would be deemed a routine cost covered by the Medicare Administrative 
Contractor (MAC). 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve the drug as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve atezolizumab.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and x-ray provided on March 27, 2023. 
 
You asked the Plan to pay for an office visit and x-ray. 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 an office visit and x-ray 
provided on March 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for annual wellness visit provided on February 22, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for annual wellness visit. You say that you are requesting reconsideration for the 
service provided. The Plan denied your request. The Plan says the enrollee must receive their care from a 
network provider (for more information about this, see Section 2 of Chapter 3). In most cases, care the enrollee 
receives from an out-of-network provider (a provider who is not part of the plans network) will not be 
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 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 annual wellness visit provided on February 22, 
2023, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on April 
30, 2023. 
 
You asked the Plan to pay for the ED services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says Medicare payment cannot be made to this type of 
provider. 
 The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period. 
 
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the emergency department (ED) services provided on April 30, 
2023.