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

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on 
January 20, 2023. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you do not agree with 
the cost share due to inconvenience and rectification services. 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 emergency care. 
 
You have been asked to pay a $125 copayment for emergency room services. 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 emergency room services 
provided on January 20, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the inpatient hospital stay provided from 
July 3, 2022, to July 4, 2022. 
 
You asked the Plan to waive the cost share for the inpatient hospital stay. You say that you did not receive 
treatment during your stay. 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 inpatient hospital care. Your 
contract with the Plan also says that there is a $500 copayment once the deductible has been met for each 
Medicare-covered hospital stay each time you are admitted.  You have been asked to pay $500, which satisfies the remainder of your deductible. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to inpatient 
hospital care. This cost sharing is a contractual obligation that had not been met at the time the inpatient 
hospital stay was received on July 3, 2022, to July 4, 2022. 
 
You have also been asked to pay a $500 copayment for the inpatient hospital stay. You have been asked to pay 
a total of $1,000 ($500 deductible + $500 copayment = $1,000). This item/service falls within the 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. Therefore, we decided that the Plan does not have to waive the cost share for the inpatient hospital stay 
provided from July 3, 2022, to July 4, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ambulance ride provided on September 03, 2022. 
 
You asked the Plan to pay for an ambulance ride. You say that this claim should be paid. 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 ambulance ride 
provided on September 03, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on October 11, 2022. 
 
You asked the Plan to pay for ambulance services. You say that the services should be covered. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for ambulance services 
provided on October 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an out-of-network  outpatient surgery 
provided on October 20, 2022. 
 
You asked the Plan to waive the copayment for an out-of-network  outpatient surgery. You say that you 
disagree with the copayment. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 
copayment for out-of-network outpatient hospital services/Medicarecovered surgery. 
 
You have been asked to pay a $125 copayment for an out-of-network  outpatient surgery. This item/service falls within the out-of-network outpatient hospital services/Medicarecovered surgery 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 out-of-network  outpatient surgery provided on October 
20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 23, 2022. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided 
on November 23, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on 
February 28, 2023. 
 
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you believe this is a 
billing error. 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 $290 
copayment for in-network outpatient surgery. 
 
You have been asked to pay a $290 copayment for the diagnostic colonoscopy. This item/service falls within 
the in-network outpatient surgery 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 medical records show a diagnostic colonoscopy was provided, and the 
outpatient surgery copayment applies. Therefore, we decided that the Plan does not have to waive the 
copayment for the diagnostic colonoscopy provided on February 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement provided on August 12, 2022. 
 
You asked the Plan to pay for debridement. 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 debridement provided 
on August 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on August 09, 
2022. 
 
You asked the Plan to pay for an office visit and related 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 an office visit and 
related services provided on August 09, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 22, 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 November 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient services provided on September 15, 2022. 
 
You asked the Plan to pay for acute inpatient services. 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 acute inpatient services 
provided on September 15, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the SNF stay provided from September 27, 
2022, to September 29, 2022. 
 
You asked the Plan to waive the deductible for the SNF stay. You say that you did not know this facility was 
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. Your 
contract with the Plan says that there is a $750 deductible which applies to out-of-network SNF care. Your 
contract with the Plan also says that there is 50% coinsurance per stay, after your $750 plan deductible, for 
each out-of-network Medicare-covered SNF stay. 
  
 You have been asked to pay a total of $603.75 towards your deductible for the SNF stay. The item or service 
you asked the Plan to waive the deductible for falls within the skilled nursing facility care benefit category. The 
Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which 
applies to skilled nursing facility care. This cost sharing is a contractual obligation that had not been met at the 
time the SNF stay was received from September 27, 2022, to September 29, 2022. Therefore, we decided that 
the Plan does not have to waive the deductible for the skilled nursing facility stay provided from September 27, 
2022, to September 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the negative pressure wound therapy 
equipment provided from December 1, 2022, to January 26, 2023. 
 
You asked the Plan to waive the coinsurance for the negative pressure wound therapy equipment. You say that 
you only used this equipment for one week. 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 2022 and 2023 contracts with the Plan clearly say that you 
must pay 20% coinsurance for durable medical equipment and related supplies.  You have been asked to pay 20% coinsurance each month for the negative pressure wound therapy equipment. 
This item/service falls within the durable medical equipment 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 the negative pressure wound therapy equipment provided from 
December 1, 2022, to January 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on November 16, 
2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that you had issues changing your 
primary care provider and could not be seen by the provider you picked. 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 $30 
copayment for urgently needed services.  
You have been asked to pay a $30 copayment for the office visit. This item/service falls within the urgently 
needed 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 records show your primary care provider was not updated before services were received, and the 
urgent care copayment applies. Therefore, we decided that the Plan does not have to waive the copayment for 
the office visit provided on November 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on July 26, 2022. 
 
You asked the Plan to pay for drug testing. 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 drug testing provided on 
July 26, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the SNF stay provided from October 12, 
2019, to October 31, 2019. 
 
You asked the Plan to waive the copayment for the SNF stay. You say that you should not have been 
transferred so many times to different facilities. 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 $0 
copayment for days 1-20 of each SNF benefit period. Your contract with the Plan also clearly says that you 
must pay a $100 copayment per day for days 21-100 of each SNF benefit period.  
 
The records show you had received 21 SNF days prior to this SNF stay. You have been asked to pay a $100 
copayment per day for days 1-17 of this SNF stay. All these days occur within the 21-100 range of this SNF 
benefit period. This item/service falls within the skilled nursing facility care benefit category. You have been 
asked to pay a total of $1,700 ($100 copayment per day x 17 days = $1,700). 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 SNF stay provided from October 12, 2019, to October 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network romiplostim injection 
provided on December 16, 2022. 
 
You asked the Plan to waive the coinsurance for an in-network romiplostim injection. You say that you should 
not have to pay this large payment. 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 Medicare Part B prescription drugs. Based on this injection, you are being asked to pay a 
coinsurance amount of $756.86 ($12.65 + $453.88 + $290.33 = $756.86). 
 
You have been asked to pay a $756.86 coinsurance for an in-network romiplostim injection.  This item/service falls 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 coinsurance for an in-network romiplostim injection provided on December 
16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lab testing to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve lab testing. You say that you want to go to this lab because years ago there 
was an issue with another lab. The Plan denied your request. The Plan says in most cases, the enrollee needs 
approval from their primary care physician (PCP) before using other providers. This approval is called a 
referral. 
 
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 
lab testing to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital outpatient clinic visit provided on December 23, 
2022. 
 
You asked the Plan to pay for hospital outpatient clinic visit. You say that you believe that 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 hospital outpatient clinic 
visit provided on December 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility services provided on August 09, 
2022. 
 
You asked the Plan to pay for skilled nursing facility services. You say that you are requesting the submitted 
documentation be reviewed. 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 skilled nursing facility 
services provided on August 09, 2022.